Suspending Reality: A future vision for Trauma Surgery

The idea of suspended animation appeals to the hidden sci-fi geek in all of us. It provokes visions of human beings floating in fluid-filled tubes for indefinite periods of time as they travel across the endless expanse of space. Indeed, space agencies have long touted suspended animation as a means of facilitating interstellar travel, with a mission to nearby Mars likely to take 7 months one-way, not to mention the further reaches of our solar system and beyond.

In the medical field, suspended animation can be defined as the temporary slowing or stopping of biological function so that physiological capabilities are preserved. The aim is to preserve cardiac and brain function to allow for subsequent surgery following exsanguination-induced cardiac arrest followed by delayed resuscitation. The theory of suspended animation (in particular that which is induced by hypothermia) is nothing new. It was Dominique Jean Larrey, a pioneer of battlefield medicine and surgeon to Napoleon’s army who observed that injured soldiers who stayed close the fire died before those who stayed hypothermic. Most prehospital trauma deaths occur due to catastrophic haemorrhage, and even with prompt patient transfer to the hospital, the time taken to identify and repair the source of bleeding and restore normal circulation in normothermic patient results in significant and irreversible metabolic derangement which patients never come back from. Rapidly slowing down metabolic activity on the other hand, gives more time for preservation of the organs and damage control surgery. The most extensively investigated approach to achieving a period of metabolic arrest has been through the use of therapeutic hypothermia. This strategy, involves rapid cooling to a core temperature of 10°C by infusion of ice-cold saline. Currently a team from the University of Maryland are in Phase 2 of the only prospective clinical trial of what they prefer to call Emergency Preservation and Resuscitation whereby eligible patients who have arrested from penetrating trauma exsanguination are rapidly cooled, have surgical control of bleeding performed and are then rewarmed with full cardiopulmonary bypass. Results remain a closely guarded secret with the study due to complete in December 2022.

So, if we are able to effectively freeze humans at the point of extremis, fix them in a relatively calm and controlled manner and then warm them up again, could this unlock the door for robotic surgery to finally make its mark in trauma? Robot-assisted surgery has become a regular sight in many elective operating lists. Its role is well recognised in urological and colorectal surgery, with the increased precision and dexterity lending itself to use in complex procedures in tight spaces i.e. the pelvis. Whilst it may not be best suited to operating on an exsanguinating patient with a belly full of blood, if said patient were to have been placed in a state of suspended animation then suddenly high-precision surgical repair with a robot becomes a possibility. There is no reason why trauma patients should not also benefit from the advantages of robotic surgery which include reduced pain, faster recovery, reduced risk of surgical site infections and minimal additional scarring.

Robots have been tested in the roles of fracture reduction, nerve repair and pelvic stabilisation. Likewise in the field of HPB, major liver and pancreatic resections as well as splenectomies are being routinely performed robotically in some centres, with early studies suggesting equivalent efficacy compared with gold-standard open surgery. As robotics makes their way into more and more operating theatres across multiple surgical specialties, familiarity with the systems and the endless drive towards innovation will inevitably result in them creeping into trauma surgery. Especially if aided by progress in the field of suspended animation.

And with the surgeon being able to control the robot from a remote location, this opens a new world of opportunity for battlefield and austere environment surgery.

Trauma Pod is a self-contained deployable robotic platform capable of performing critical diagnostics and acute life-saving interventions in the field for an injured person who might otherwise die from loss of airway, haemorrhage or other acute injuries, such as tension pneumothorax. It will either operate autonomously or under tele-operative control with researchers claiming it capable of performing vascular shunts and bowel anastomosis. Other capabilities include the ability to obtain an airway, perform haemostasis, manipulate damaged tissues and place monitoring devices. The Trauma Pod will be used when the timely deployment of proper medical personnel is not possible or too risky and the patient cannot be evacuated quickly enough to an appropriate medical facility.

Image taken from Garcia et al Int J Med Robotics Comput Assist Surg 2009; 5: 136–146.

Imagine a Trauma Pod deployed to humanitarian disasters home and abroad, treating a farmer in a field in the middle of nowhere, or treating the casualties of armed conflict anywhere in the world. The patient is rapidly cooled to a point of suspended animation and damage control and/or definitive surgery takes place, all while the patient is in transit to a more suitable care setting.

The future of trauma care is only limited by our imaginations. COVID made us rise to the challenge and fast-track the introduction of new technologies and new ways of working, building on telemedicine ideas that have been circulating for decades. As we enter 2022, we must remain poised to thrown technological solutions at whatever new challenges we face. As always history has a lot to tell us about where we are heading.

Obi Nnajiuba is a British surgical resident with a specialist interest in trauma, acute care, prehospital care, triage, mass casualty events and trauma systems. His postgraduate qualifications include an MSc in Trauma Sciences and membership of the Royal College of Surgeons of England. He is also a registered Motorsport UK physician, providing trackside advanced trauma care to competitors at world famous motor-racing circuits such as Brands Hatch, Goodwood and Silverstone.

@drnnajiuba

Can the heroes become the villains?

For better or for worse, trauma surgeons often cultivate the aura of the stereotypical hero surgeon who operates in hectic and fast-paced environments with lots of shouting, off-the-cuff decision-making and fearlessly dragging people back from the brink of death no matter how unlikely the odds of survival. And some surgeons, perhaps egged on by this imagery, do try to live up to it.

We’re now better equipped than ever to salvage the previously unsalvageable patient. People who would have died in the street 10 or 15 years ago are now making it into resus, into theatre and onto the ICU. But at what cost? We seldom have the luxury of knowing what a patient’s core beliefs are and how this might influence the value they place on being fully independent as opposed to paralysed and reliant on carers 24/7. The indignity of relying on someone else for personal hygiene or the loss of the simple ability to take a walk to the park cannot be underestimated. Many patients would rather be dead than lose their independence, hence the enduring allure of Swiss assisted-suicide clinics.

I recall vividly the young man who stepped out in front of a train and was brought into my trauma centre with traumatic bilateral hindquarter amputations. Coincidentally, the incident had taken place at my local rail station where I had gotten the train to work that very morning. As we formalised his traumatic amputations and performed a crash laparotomy on him to gain proximal vascular control, I couldn’t help but think that if this guy was already at such a nadir that he sought to kill himself in such a gruesome way, then how will his mental state be improved by waking up to find he has no legs and a stoma? Of course, there are questions of mental capacity and whether one can truly weigh up the pros and cons of wanting to live or die when in the throes of depression. But what of the young TBI patient doomed to be left in a vegetative state or with locked-in syndrome, never again able to fully communicate their wishes. Despite the emotions involved, the decision to operate can’t be influenced by the clinician’s hunch as to whether a person wants to be saved.

Perhaps all of us, young and old, fit or otherwise need to have in place some kind of advanced directive that states that we should be left to die in the event that a major traumatic injury leaves us with significant disability and a diminished quality of life. Perhaps we ought to engage in this difficult discussion with our loved ones beforehand akin to the way we ought to talk about organ donation. The definition of ‘significant disability’ and ‘diminished quality of life’ is a highly subjective one and therefore must be determined by the patient when they’re of sound mind and body before any tragedy strikes.

Last month the British Medical Association moved to adopt a neutral stance on assisted dying which it had previously been opposed to. Such a paradigm shift is indicative of a gradual change in societal attitudes. It also acknowledges that there is nuance to life and death and that preserving life at all costs may not always be in a patient’s best interests. It’s hard to see how this discussion could be incorporated into to a fast-moving trauma resuscitation scenario, especially when many patients show up in the trauma bay without a name, let alone a detailed précis of their wishes and expectations for quality of life. Furthermore, the extent of their injuries and the long-term sequelae are often unknown in the initial hours and days.

We still must fix what’s in front of us and act in what we deem to be the patients’ best interest, which for most cases (especially the younger, healthier trauma demographic) means pulling out all the stops to keep them alive irrespective of injury severity. However, it doesn’t stop us having the conversations and keeping in mind that life is an experience that means so much more than simply having a cardiac muscle that beats.

Trauma Surgery Shouldn’t Mean Sloppy Surgery

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.

Regionalization of Emergency General Surgery: Is Transfer Worth the Risk?

Regionalization of Emergency General Surgery: Is Transfer Worth the Risk? The regionalisation of emergency general surgery (EGS) services remains an ongoing point of discussion for surgeons and service managers alike. As with other areas such as trauma, vascular surgery, cancer, MI and stroke services, there are pros and cons to regionalisation with perhaps even less evidence than in the aforementioned specialties to convincingly sway opinion one way or another. EGS patients with their myriads of co-morbidities and complications inevitably require more ITU support and multidisciplinary input which may be more readily provided at specialist units.

The patient population on the whole tend to come from poorer socioeconomic backgrounds with relatively inferior medical facilities who may benefit from direct triage to specialist EGS centers, especially given that emergency care in many hospitals is at breaking point. Also, there is a well described relationship between patient volumes and outcomes, especially for high-risk patients presenting in shock or with peritoneal contamination and vascular injuries.

This volume-outcome relationship has very much being the drive behind the Take The Volume Pledge, an initiative driven by leaders at Dartmouth-Hitchcock Medical Center, Johns Hopkins and the University of Michigan Health System aiming to place limits on emergency surgery being carried out at low volume centres.

 On the other side of the arguments there are those who would say that transferring sick patients between hospitals is itself a risk factor for poor outcome and that there is likely to be a knock-on effect on other specialties at designated EGS centres such as delays to theatre for other urgent but less imminently life-threatening conditions. Transferring patients to regional centres where they may be far removed from their own family and social support networks may also be detrimental to the mental wellbeing of patients and their families.

In the UK the model is increasingly moving to one where EGS is its own stand-alone specialty with consultants (attending physicians) focusing their time almost exclusively to the care of these patients, with limited scope for other clinical activities such as lucrative work in the private sector. Not surprisingly, this has led to a negative perception in some quarters, with many surgical trainees shunning the positions which are often filled by foreign graduates or non-trainee surgeons who (for reasons of bureaucracy rather than competency) often struggle to get regular consultant posts in an established and more competitive surgical specialties. No one, not least your average egotistical surgeon wants to be seen as a second- class citizen within their sphere of operation.

The workforce issue is no less a problem back in the US given that there is a dwindling and ever ageing pool of pure general surgeons from which the EGS surgeon cohort is drawn. Of the approximately 1000 general surgery chief residents who graduate annually, only around 300 pursue general surgery careers.

In theory there should be few obstacles to formally establishing centralised EGS centers at hospitals with existing acute care surgery (ACS) programs, combining the critical care and trauma elements with EGS. Before moving full steam ahead with centralisation there is a need for a trusted evidence-based triage tool which can identify the EGS cohort most likely to benefit from transfer and/or those most likely to suffer harm from remaining in their local hospital.

Obi Nnajiuba is a British surgical resident with a specialist interest in trauma, acute care, prehospital care, triage, mass casualty events and trauma systems. His postgraduate qualifications include an MSc in Trauma Sciences and membership of the Royal College of Surgeons of England. He is also a registered Motorsport UK physician, providing trackside advanced trauma care to competitors at world famous motor-racing circuits such as Brands Hatch, Goodwood and Silverstone.

Race for Life

Trauma surgeons arguably have much to offer in the pre-hospital arena. Whilst countries such as the UK have been more gung-ho in getting surgeons out in the field performing roadside thoracotomies and the like, there remain a number of sporting events that mandate an advanced trauma response team on-site, which will often include a surgical presence.

Perhaps the highest-profile of these events is motorsports. Surgeons have a significant place in the history of safety improvement in the world of motorsport, none more so than the late great Sid Watkins, a British neurosurgeon who from 1962-1970 was the Professor of Neurosurgery at SUNY, Syracuse and spent much of his free time at the Watkins Glen circuit in Schuyler County, NY.

He served as the Formula One Medical Delegate for 30 years and over the decades pioneered advances in trackside safety by instigating the use of medically equipped cars, medivac helicopters and fully stocked medical centres allowing ICU facilities to be brought to the drivers at their time of need.

Thousands of surgeons such as myself and other trauma physicians around the world now spend a considerable amount of their free time on standby at race circuits ready to provide advanced trauma care to race competitors, with drivers walking away from huge crashes owing to a combination of improved car technology, better materials, improved fire safety and medical care being just seconds away.

Compare that to crashing your car on a highway in the middle of nowhere and one could argue that doing 200mph on a dedicated racetrack at a fully licensed event may well be safer than the drive to and from the venue!

How does my role trackside compare with my role in a regular trauma call at my hospital? On a quiet day, it’s a sweet gig being sat trackside in a comfortable pimped-out SUV with a close-up view of the action and access to competitors that the best tickets in the house can’t buy. But all that can be flipped in an instant, and when things go wrong, they can go really wrong.

When I pull up at an incident with my paramedic colleague, I am the airway guy, primary surveyor, team leader, and decision-maker all wrapped up in one. The availability of local air ambulance services means backup and rapid transportation to the hospital is normally readily available, however, medics operating outside of their familiar hospital environments can feel incredibly exposed and vulnerable during this initial phase of care. Provision of motorsport medical services often comes with a rise in medical indemnity fees.

Whether or not mistakes made in the relatively austere prehospital environment should be judged more leniently than mistakes made in hospitals is up for debate. Thankfully it’s the track owners themselves rather than the doctors they contract that are usually in the firing line for litigation. It’s likely a race competitor’s death would have more to do with poor track design and misfortune than pure medical negligence. And it’s not all wall-to-wall ATLS. Medical emergencies among drivers, their teams, and the crowds that follow are not unheard of.

There are plenty of cases of amateur racers having a medical primary cause for their crash, be it an MI or hypoglycaemic episode. And the last time I had to treat a patient who was hemodynamically unstable from atrial fibrillation it was in fact one of the elderly officials up in the race control tower who had clearly had too much excitement for one day. With that in mind, there is no particular reason why any suitably trained physician shouldn’t be able to offer their service at these events.

Over the years I’ve worked alongside family physicians, obstetricians and even ophthalmologists, all of whom have been ATLS-trained and conversant in the language of trauma resuscitation in the 21 st century.

Some of our colleagues have paid the ultimate price in their roles. Dr. John Hinds, an anaesthesiologist and bike racing enthusiast from Northern Ireland was killed responding to a road race incident on his own motorcycle in 2015. Dr. Hinds was hugely respected, the world over thanks to his entertaining lectures and first-hand experience of the motorsport world both from a competitor’s and physician’s perspective. His death is a constant reminder that real lives are at stake on both sides of the crash barrier and as with most things in medicine, vigilance and a healthy dose of respect for the beast will always go a long way.

Obi Nnajiuba is a British surgical resident with a specialist interest in trauma, acute care, prehospital care, triage, mass casualty events and trauma systems. His postgraduate qualifications include an MSc in Trauma Sciences and membership of the Royal College of Surgeons of England. He is also a registered Motorsport UK physician, providing trackside advanced trauma care to competitors at world famous motor-racing circuits such as Brands Hatch, Goodwood and Silverstone.

Trauma Innovation: 2020 and beyond

The year 2020 has been dominated by COVID and its myriad implications for delivering safe and effective trauma care alongside the changes imposed on our working practices and general way of life. The collective attention of the world’s scientific community and consequently the financial backing to go along with it has been concentrated on developing effective treatments and vaccines to combat the virus. The economic, physical and mental health implications of having a similar or even worse 2021 do not bear thinking about. It is a testament to the human spirit that a number of seemingly effective vaccines have been developed and rolled out in a matter of months.

 Whilst not progressing at a similar pace, the world of trauma and injury has continued to see a number of technological innovations that may well shape things for years to come. Not least in the often-neglected world of trauma rehabilitation.

 Wearable bionics are playing a growing role in patient rehab and the restoration of independence after debilitating injury. Weight re-distributing exoskeleton devices such as the Paexo Back are finding increasing popularity in the warehousing and distribution industries where back pain and repetitive strain injuries are a leading cause for sickness absence. The EksoNR system is the latest in a line of exoskeleton systems developed by Ekso and has received FDA approval as a powered exercise device for rehabilitative purposes. Initiating movement through body weight shifts and external controls, the device is most useful for patients with mid-thoracic to lower lumbar spinal cord injuries. A clinical trial evaluating its effectiveness commenced at the beginning of the year and is due to report its findings in due course.

Neural interfaces or brain-computer interface devices establish a direct communication pathway between the brain and external devices enabling faster and more intuitive communication and control for individuals with motor disabilities. What differentiates them from traditional assistive devices is that user commands are extracted directly from brain activity without the need for users to exert any overt movement. Motor system neurophysiology studies have shown how the activity of motor cortical neurons are modulated by movement and that firing rates of a population of motor cortical neurons can be used to predict hand movement direction, speed, and position. Motor function can then be elicited via cutaneous electrodes in a process known as functional electrical stimulation (FES). FES devices continue to get more compact and more capable as the years go by and as developments in artificial intelligence continue to bear fruits, with an example being the  L100 Go from Ottobock  which is a minimalist cuff-based system designed to fit around the leg beneath clothes and treat drop foot.

 Peripheral nerve regeneration remains one of the great challenges of rehab and regenerative medicine. Existing treatments include nerve grafting, which has a limited success rate and a number of drawbacks common to any kind of graft or transplant surgery. Electrical signals can offer critical bioactive cues to promote neurite extension and accelerate nerve functional recovery. There were promising results from a Chinese group [HN6] this year who developed a biodegradable, self-electrified, and ultra-miniaturized conduit device for promoting peripheral nerve regeneration, which simultaneously offers structural guidance and sustained electrical cues without additional surgical complications. The device made from a dissolvable galvanic cell was successfully tested on rat models and may well be making its way into humans in the near future.

 The year 2021 promises to start off where 2020 finishes. In the midst of a global pandemic, with a large amount of the money, equipment and research attention diverted to COVID. As we begin to get on top of things there will no doubt be more exciting news to emerge from the world of trauma.

Obi Nnajiuba is a British surgical resident with a specialist interest in trauma, acute care, prehospital care, triage, mass casualty events and trauma systems. His postgraduate qualifications include an MSc in Trauma Sciences and membership of the Royal College of Surgeons of England. He is also a registered Motorsport UK physician, providing trackside advanced trauma care to competitors at world famous motor-racing circuits such as Brands Hatch, Goodwood and Silverstone.

 @drnnajiuba

A need for generalist skills in a sub-specialised world

The term ‘general surgeon’ is somewhat misleading in todays age of sub-specialisation. In years gone by the same surgeon performing the Whipple’s may well have been doing a thyroidectomy the following day, and though somewhat admirable, this jack-of-all-trades mentality may not always lend itself to achieving the best results for patients.

Polytrauma usually pays no regard to anatomical boundaries and sub-specialties; therefore, the skills of a true generalist are coveted in time-critical scenarios. In an ideal world the trauma surgeon must be equally as comfortable and competent in the neck, limbs and chest as they are the in abdomen. Improvements in prehospital management mean that more patients are surviving  to hospital with major injuries. We expect these patients to survive and get the best treatment possible

The need for true generalist skills means that trauma surgeons have benefited from the somewhat leisurely and convoluted training pathways of years gone by. A general surgeon’s formative years may well have included rotations through cardiothoracics, neurosurgery, ENT and even orthopaedics. This breadth of experience all adding to one’s inventory, providing the trauma surgeon with various hacks, surgical exposure tricks and anatomical pearls of wisdom to see them through the most demanding of cases. But the streamlined training pathways of the modern era leave little opportunity for the slow osmotic absorption of information, with residents encouraged to sub-specialise early and become experts in their own little field, all while spending fewer hours in the hospital. The Resident Education Committee of the Society for Surgery of the Alimentary Tract (SSAT) offered up a comprehensive review of the paradigm shift towards sub-specialisation and some of the key drivers that include residents’ perceptions of increased marketability, compensation and better work-life balances.

In the UK, vascular surgery used to be an integral part of general surgical training. A few years ago, vascular surgery became its own entirely separate residency programme, with vascular trainees more heavily focused on evolving endovascular skills and only needing to do a year of general surgery. Conversely,  general surgery residents are only required to do 6 months of vascular surgery in an entire 6-year program. As a result, the future cadre of general and vascular surgeons will have significantly reduced skills in the alternate specialty, leaving those set on a career as trauma surgeons with a lot of catching up to do in the form of post-residency fellowships and extra experience sought overseas.

In the US there are movements afoot triggered by this modern push to sub-specialise early. Rural surgery fellowships are growing in popularity, aiming to teach enough of everything to see a surgeon through a career of working in relatively remote or austere environments, including basic obstetrics and urology skills. This will help to address the anticipated shortfall in non-urban general surgery trainees coming through the system. Additionally, there is the regionalisation of acute care surgery much in the same way that trauma care has long been regionalised. Whether or not patient outcomes will benefit from the regionalisation of emergency surgery to specialist centres in the same way that trauma patient outcomes have benefited remains to be seen.

It is not uncommon nowadays to see new trauma attendings being mentored and baby-sat in theatre by more senior colleagues. Whilst there may now be an expectation that technical skills will need to be continually honed through the early attending years, the emphasis on the non-operative skills of surgery such as leadership, decision-making skills and communication continues to grow. The question is, who makes a better and safer ‘day one’ attending trauma surgeon? The surgeon who knows their limits, knows who to call for help early and maintains strategic oversight of the patient journey? Or the surgeons who thinks they can handle everything and does just about an ok (but not great) job on the operating table? And are having excellent operative and non-operative skills or excellent general and subspecialty surgical skills mutually exclusive? As high-fidelity surgical models and augmented reality technologies continue to develop, will there be an even greater place for simulation in bringing new surgeons fresh out of residency up to speed with all of the skills required of a generalist trauma surgeon?

As with so much in medicine, little if any evidence backs the current direction of travel. As the generation of truly old school general surgeons continues to edge closer to retirement, who will be left to teach us the old ways should we decide that being a benign proctologist isn’t cutting it when it comes to saving the life of a man hosing out from the neck?

Obi Nnajiuba is a British surgical resident with a specialist interest in trauma, acute care, prehospital care, triage, mass casualty events and trauma systems. His postgraduate qualifications include an MSc in Trauma Sciences and membership of the Royal College of Surgeons of England. He is also a registered Motorsport UK physician, providing trackside advanced trauma care to competitors at world famous motor-racing circuits such as Brands Hatch, Goodwood and Silverstone.

@drnnajiuba

High Performance Surgeons Need High Performance Coaching

Visualise for a moment an image of Usain Bolt preparing for the 2016 Rio Olympics under the watchful eye of precisely no one. Out there day and night sprinting on the practice track with a stopwatch in one hand trying to time his runs and simultaneously focus on his stride  technique. Or imagine Rafael Nadal training for the US Open by hitting a tennis ball up against a brick wall and pretending there’s a human being hitting the ball back at him. Despite a combination of God-given talent, dedication to their craft and an overwhelming desire to win, there is only so far an elite athlete can go without elite level coaching to guide the way. Coaching is about maximising performance by unlocking an individual’s inherent abilities and in doing so helping them to achieve their own personal and professional goals.

Nadal doesn’t need to be taught how to play tennis any more than a competent attending surgeon needs to be shown how to do a laparotomy. But why is it that elite coaching for elite athletes is seen as a given, yet elite coaching for medical professionals and leaders making daily life-or-death decisions is still something of an abstract concept? If an athlete has a bad day, they may lose a game or a championship title but at least everyone goes home alive, or at least not maimed (combat sports and Mike Tyson  notwithstanding). 

Coaching has become well established in the business and financial world. The professional goals of  team-building, conflict management, organisational effectiveness and strategic thinking are easily transferable to any senior clinician who finds themselves juggling clinical, academic and training commitments whilst trying to maintain a family life of their own. Evidence continues to emerge championing the benefits of coaching in terms of clinical performance and clinician well-being, with an emphasis on reducing burnout. 

Coaching is not only for those at the top of the professional tree. Many residents find that the transition from one stage of training to another can unleash all manner of uncertainty and self-doubt which only serves to stifle performance and impede professional growth. Classically, those returning to residency from a prolonged period of absence such as research or maternity leave suffer the most. Increasingly, training boards and organisations are setting aside the resources to address this. For example, trainees in London and many other parts of the UK have free access to professional coaching services through their educational board’s Professional Support Units (PSU). Among many things, recipients are forced to challenge cognitive distortions, understand their core values, pursue 360-degree feedback from peers and clinical supervisors and build towards having the ability to self-coach in a way that sustains them long after the free sessions have ended. And the benefits of coaching need not be confined to trainees who find themselves in difficulty. A randomised study of a group of Canadian residents in 2015 published in the Annals of Surgery showed significantly better procedure-specific skills and fewer technical errors among those subject to comprehensive surgical coaching as opposed to conventional training. A later study  from 2018 in the same journal detailed the Wisconsin Surgical Coaching Program in which surgeons of varying levels of experience were coached by senior peers who had been trained in coaching techniques. Videos of surgical procedures were jointly reviewed in sessions focussing on the technical, cognitive and interpersonal skills displayed. The sessions were judged objectively and subjectively to have been effective and spoke to the benefits of flattening hierarchy within the surgical profession.

Now more than ever at a time when the surgical workforce has been pushed to its physical and emotional limits there is a need for more widespread provision and engagement of coaching services. A surgical career is a marathon, but even the greatest distance runners still need someone to help them realise their full potential.

Obi Nnajiuba is a British surgical resident with a specialist interest in trauma, acute care, prehospital care, triage, mass casualty events and trauma systems. His postgraduate qualifications include an MSc in Trauma Sciences and membership of the Royal College of Surgeons of England. He is also a registered Motorsport UK physician, providing trackside advanced trauma care to competitors at world famous motor-racing circuits such as Brands Hatch, Goodwood and Silverstone.

@drnnajiuba

A House Built on Sand

The word ‘judgment’ appears in the first sentence of the classical Hippocratic Oath. Evidence-based honest judgement has been a cornerstone of the art and practice of medicine for thousands of years. Our clinical decisions are guided by evidence disseminated in the medical literature and whether this is distilled down via Twitter infographics or scrutinised in a journal club there is a chain of events that will have guided the scientific conclusions.

That chain involves patient selection, accurate data collection, accurate data aggregation, statistical analysis, interpretation, synthesis of findings into a paper and then acceptance of the conclusions by the scientific community. Errors along the chain are magnified by the time these conclusions are drawn. Fundamental flaws in study design and interpretation not only ruin careers but more importantly destroy lives and erode the trust that is placed in us by the public. Furthermore, it can provide ammunition for all manner of anti-vaxxer type loons and shady stakeholders.

The unfolding Surgisphere scandal is a spectacular case in point. The WHO pulled the plug on worldwide clinical trials involving hydroxychloroquine in the treatment of COVID-19 based on the results of a now retracted international study published in The Lancet, a byword for reputable medical information. The Lancet study used patient data collated by a largely unknown multinational ‘global research network’ by the name of Surgisphere to demonstrate a supposed increase in mortality risk from using hydroxychloroquine to treat COVID-19. Surgisphere claimed to have obtained data from more than a thousand hospitals worldwide yet the veracity of this data is now under close scrutiny. The bottom line is the medical community made an assumption of trustworthiness based on the fact that this data was published in the Lancet. Having said that, this wouldn’t be the first case of bad science making it into this particular journal as anyone who has had to have the “MMR doesn’t cause autism” conversation with parents will attest to.

 In the midst of an unprecedented global pandemic with every nation battling to reignite their stagnant economies and people longing for a return to normality there will inevitably be a rush to publish data, especially data that gives hope. And where there is haste there will be corners cut and mistakes made. It’s becoming something of a Wild West out there with the Commander-in-Chief shooting misinformation from the hip, mixed public health messaging and inaccurate COVID test products flooding the market. In May the House Subcommittee on Economic and Consumer Policy reported that in April alone over 150 such tests had gone to market without any FDA review.

 The big question is should events like the Surgisphere debacle spark a change in how we use data to make decisions? Do we need to be more questioning of research from supposedly reputable sources and less snobbish about research from lesser known outlets? What are the alternatives to evidence-based medicine? Surgeons in particular are renowned for indulging in daily idiosyncratic practices that have little evidence base.

 Perhaps in a world of big data that moves at breakneck speed and where attention spans are shorter than ever, we just have to accept that bad science will creep in at times and hope to minimise its impact when it does.

Obi Nnajiuba is a British surgical resident with a specialist interest in trauma, acute care, prehospital care, triage, mass casualty events and trauma systems. His postgraduate qualifications include an MSc in Trauma Sciences and membership of the Royal College of Surgeons of England. He is also a registered Motorsport UK physician, providing trackside advanced trauma care to competitors at world famous motor-racing circuits such as Brands Hatch, Goodwood and Silverstone.


@drnnajiuba

Our profession is not immune from ignorance and micro-aggression

The past few weeks have exposed the bitter and entrenched racial divides that continue to persist in western societies. None more so than in the United States, which with its unique history of industrial-scale enslavement and segregation laws seems to be battling with a more visceral manifestation of racism than any other developed country in the world. The majority of people are not overtly racist. Yet outlawing the Ku Klux Klan and not using the n-word are simply the tip of a vast pyramid of covert and institutionalised racism which frustrates the lives of black and ethnic minority people on a daily basis. The medical field, for all its virtuous ideals, is not immune from this.

Using myself as one small insignificant example. As a black surgeon I’ve lost count of the number of times I’ve been stopped in a hospital corridor by nurses or other doctors  and asked to take a patient to the x-ray department. The assumption being that I must be a porter. The apologies and embarrassed expressions on people’s faces when I correct them highlights the fact that these people aren’t actively racist, they’re just steeped in unconscious bias. At the lower end of the scale this leads to pleasant misunderstandings, but at the more extreme end it leads to black men being perceived as ‘dangerous’, resulting in frightened women needlessly calling 911 and prompting a more aggressive and at times deadly response from police when they show up.

Black and minority doctors (foreign graduates in particular) may find themselves excluded from the alcohol-centred after-work social circles for any number of cultural or religious reasons. These networking opportunities grease the pathway of career progression for many and help with the formation alliances that can be called upon for support in the midst of legal difficulties or disciplinary proceedings. Minority doctors are more likely  to find themselves hauled in front of professional misconduct panels and receive harsher penalties than those of their white counterparts.

The Eastern Association for the Surgery of Trauma (EAST)  led the way last year through its new Equity, Quality, and Inclusion Task Force. Under the banner of #EAST4ALL they aimed to highlight and tackle the difficulties faced by surgeons as a result of unconscious bias against their race, gender, religion, sexuality and country of origin among other things. In recent weeks the AAST has reaffirmed its commitment to fighting all forms of discrimination.

We know that racial bias can affect the quality of communication  and patient-centred care delivered. Specifically, in trauma, minority patients have been shown to cluster at trauma centres with worse than expected mortality outcomes. Other studies have highlighted the perception of pain thresholds in black patients to be higher than those of white patients leading to patients’ analgesic requirements going ignored and perhaps even playing a part in the higher rate of maternal deaths among black women.

More and more institutions are offering resources to empower white staff members to become allies of their minority colleagues. Departmental leads must commit to cultural shifts and the enforcement of departmental policies that deal with discrimination and bias expressed by patients as well as colleagues. Diversity and inclusiveness within organisations leads to new creative ways of thinking and the development of novel solutions for old problems. We must all be made to feel comfortable and worthy of our seat at the table.

Obi Nnajiuba is a British surgical resident with specialist interests in trauma, acute care, prehospital care, triage, mass casualty events and trauma systems. His postgraduate qualifications include an MSc in Trauma Sciences and membership of the Royal College of Surgeons of England. He is also a registered Motorsport UK physician, providing trackside advanced trauma care to competitors at world famous motor-racing circuits such as Brands Hatch, Goodwood and Silverstone. 

@drnnajiuba