ACS Practice Patterns Survey, Part II

FEATURES

Fahad’s journey 8 Sylvia D. Campbell, MD, FACS

ACS Practice Patterns Survey, Part II: Prescribing habits among surgical specialties 11 Charles M. Balch, MD, FACS; and Thomas R. Russell, MD, FACS

Into the theater: Perspectives from a civilian trauma surgeon’s visit to the Combat Support Hospital in Balad, Iraq 16 M. Margaret Knudson, MD, FACS

2008 state legislative activity 26 Melinda Baker

DEPARTMENTS

From my perspective 4 Editorial by Thomas R. Russell, MD, FACS, ACS Executive Director

Dateline: Washington 7 Division of Advocacy and Health Policy

Socioeconomic tips 31 ACS Coding Hotline: Cholecystectomy questions Linda Barney, MD, FACS; Albert Bothe, Jr., MD, FACS; and Debra Mariani, CPC

NOVEMER 2008Volume 93, Number 11

On the cover: A Ugandan mother’s plea on behalf of her son, who suffered from a heart complication, inspired dedicated surgeons and nonsurgeons in Tampa, FL, to coordinate stateside care for the child (see article, page 8).

Stephen J. RegnierEditor

Linn MeyerDirector of

Communications

Karen SteinAssociate Editor

Diane S. SchneidmanContributing Editor

Tina WoelkeGraphic Design Specialist

Alden H. Harken, MD, FACS

Charles D. Mabry, MD, FACS

Jack W. McAninch, MD, FACS

Editorial Advisors

Tina WoelkeFront cover design

Future meetingsClinical Congress2009Chicago,IL, October11-15

2010Washington,DC, October3-7

2011 SanFrancisco,CA, October23-27

Letters to the Editor should be sent with the writer’s name, address, e-mail ad-dress, and daytime tele-phone number via e-mail to [email protected], or via mail to Stephen J. Regnier, Editor, Bulletin, American College of Surgeons, 633 N. Saint Clair St., Chicago, IL 60611. Letters may be edited for length or clarity. Permission to publish letters is assumed unless the author indicates otherwise.

Bulletin of the AmericanCollege of Surgeons (ISSN 0002-8045) is published monthly by the American Col-lege of Surgeons, 633 N. Saint Clair St., Chicago, IL 60611. It is distributed without charge to Fellows, Associate Fellows, Resident and Medical Student Members, Affiliate Members, and to medical libraries and al-lied health personnel. Periodi-cals postage paid at Chicago, IL, and additional mailing offices. POSTMASTER: Send address changes toBulletinoftheAmericanCollegeofSur-geons,633 N. Saint Clair St., Chicago, IL 60611-3211. Cana-dian Publications Mail Agree-ment No. 40035010. Canada returns to: Station A, PO Box 54, Windsor, ON N9A 6J5. The American College of Surgeons’ headquarters is located at 633 N. Saint Clair St., Chicago, IL 60611-3211; tel. 312/202-5000; toll-free: 800/621-4111; fax: 312/202-5001; e-mail:postmaster@ facs.org; Web site: www.facs. org. Washington, DC, office is located at 1640 Wisconsin Ave., NW, Washington, DC 20007; tel. 202/337-2701, fax 202/337-4271. Unless specifically stated otherwise, the opinions ex-pressed and statements made in this publication reflect the authors’ personal observations and do not imply endorsement by nor official policy of the American College of Surgeons.

©2008 by the American College of Surgeons, all rights reserved. Contents may not be reproduced, stored in a retrieval system, or transmit-ted in any form by any means without prior written permis-sion of the publisher. Library of Congress number 45-49454. Printed in the USA. Publications Agreement No. 1564382.

NEWS

Dr. Cameron installed as 89th ACS President 33Honorary Fellowships presented to five prominent surgeons 34

Citation for Prof. Jacques Brotchi 35 Fernando G. Diaz, MD, PhD

Citation for Prof. Joaquim Gama-Rodrigues 36 Carlos A. Pellegrini, MD, FACS

Citation for Prof. Gerald C. O’Sullivan 37 Tom R. DeMeester, MD, FACS

Citation for Mr. Bernard Ribiero 38 George F. Sheldon, MD, FACS, FRCSEd(Hon), FRCSEng(Hon)

Citation for Prof. Russell W. Strong 40 L. D. Britt, MD, FACS

In memoriam: James C. Thompson, MD, FACS, 1928–2008 42 Marshall J. Orloff, MD, FACS

Germany Traveling Fellow selected for 2009 47

Dr. Eastman appointed to national injury prevention advisory board 47

Report of the 2008 American College of Surgeons Japan Traveling Fellow 49 Sam M. Wiseman, MD, FACS, FRCSC

A look at The Joint Commission: International focus on accreditation 55

Trauma meetings calendar 55

ACOSOG news: “Such stuff as dreams are made on”: Laparoscopic rectal cancer trial 56 David M. Ota, MD, FACS; and Heidi Nelson, MD, FACS

2009 Oweida Scholarship availability announced 57

NTDB® data points: ATVs: “All-terrain victims” 59 Richard J. Fantus, MD, FACS

The American College of Surgeons is dedicated to improving the care of the sur-gical patient and to safeguarding standards of care in an optimal and ethical practice environment.

Establishment of the ACS Health Policy and Research Institute presents an opportunity for the American College of Surgeons to play a true leadership role in the health policy arena.’’

’’

Frommyperspective

Earlierthisyear,theAmericanCollegeofSurgeonsannouncedtheestablishmentof a new Health Policy and ResearchInstitute, which is currently based at

the University of North Carolina (UNC), Cha-pelHill.AlreadythisinstituteisenhancingtheCollege’s capacity for analyzing issues and de-velopingthoughtfulpositionstatements,andweanticipatethatitwillassistthisorganizationinoureffortstobecomeanincreasinglyprominentpresenceinthepolicymakingarena.

Initial stepsStart-upofthisimportantbranchoftheCollege

isbeingledunderthecarefulguidanceofGeorgeF. Sheldon, MD, FACS, Zack D. Owens Distin-guished Professor of Surgery at UNC’s SchoolofMedicine.Dr.Sheldon,aPast-PresidentoftheCollege,wasselectedforthispositionthroughanationalsearchprocess.Heisreceivingadminis-trativeassistancefromThomasJ.Ricketts,PhD,deputydirectoroftheUNCCecilG.ShepsCenterforHealthPolicyResearch.

The Cecil G. Sheps Center for Health PolicyResearch is an institute within the UNC thatreports to the vice-chancellor and collaborateswith the schools of medicine, dentistry, publichealth, nursing, and allied health. The centerhas 140 full-time time researchers, numerousgraduatestudents,andsubstantialexistinggrantsupportfromtheHealthResourcesandServicesAdministration,theAgencyforHealthcareRe-searchandQuality,andtheNationalInstitutesofHealth.

This collaboration with an existing healthpolicyresearchcenterisanewmodelthatallowsaprofessionalorganization,suchastheCollege,tocollaboratewithdemographers,statisticians,surveyexperts,andotherexpertsinhealthser-vices research. The collaboration between theAmerican College of Surgeons and UNC alsoensures that the ACS Health Policy and Re-searchInstitutehasaccesstotheresourcesandknowledge necessary to cultivate a nationallyrespectedthinktank.Drs.SheldonandRickettsarebothhighlyregardedauthoritiesonhealthcareissues,andtheShepsCenterhasalonganddistinguishedrecordinconductinghealthpolicyresearch.BasingtheinstituteatUNCduringitsearlystagesofgrowthhasallowedustoinitiate

our efforts much more quickly than if we hadattempted to build an entirely new programfromscratch.

Exploratory projects under wayForitsfirstproject,theACSHealthPolicyand

Research Institute is studying surgeon work-forceissues.Morespecifically,theresearchersattheinstituteareattemptingtoanswerquestionsabouthowmanysurgeonswillbeneededtoen-surepatientaccesstocareinthefuture,whichspecialties need to attract more trainees, andthecausesofgeographicdisparitiesinaccesstosurgicalcare.Dr.SheldonandhisteamatUNChave already conducted considerable researchregarding the impending surgical workforcecrisisandhavestartedtogenerateideasabouthowthefederalgovernmentcanhelptoensurethatsurgeonsareaccessibletothepatientswhoneedtheirservices.

Based on the institute’s research, the Col-legehasarrivedatsomeofthesuggestionswe

VOLUME93,NUMBER11,BULLETINOFTHEAMERICANCOLLEGEOFSURGEONS

4

intendtooffertohealthpolicymakerstoassisttheminaddressingtheworkforceissue.Theserecommendations include the following: (1)encouraging a well-planned expansion of U.S.medicalschoolgraduatesandresidencytrain-ing programs, (2) providing federal financialsupport for specialties with lengthy trainingrequirements, (3) eliminating caps on thenumber of residents eligible for federal sup-portateachtraininginstitution,(4)expandingprograms that give financial support to ruralphysicians to include surgical specialists, and(5)providingincentivesforsurgeonstotakecallinournation’straumacentersandemergencydepartments.

WeanticipatethattheACSHealthPolicyandResearchInstitutewill continuetoplayan in-strumentalroleinhelpingtheCollegetodevelopspecific,scholarly,well-conceivedstrategiesthatlawmakerscanapplyinreformingthenation’shealthcaredeliverysystem.Forexample,asCon-gressandtheCentersforMedicare&MedicaidServicesstrivetocreateavalue-based,patient-driven schematic, surgeonswill facemountingpressures to document the effectiveness andefficiencyoftheworktheydo.Theinstitutewillbeusefulingeneratingdatathatcanshowwhatsurgeonsaredoingwellandwherethereisroomforimprovement.

Furthermore,theinstitutewillserveasathinktank where clinical scholars can examine anddiscussthecomplexitiesofsurgicalpracticeandcreateavisionforthefutureofourprofession.Currently, the College’s Division of ResearchandOptimalPatientCareisbenefitingfromtheassistance of three young research fellows, in-cludingaRobertWoodJohnsonClinicalScholarandtwonewClinicalScholarsinResidence(seerelatedstoryonpages93–94oftheJulyBulle-tin).WeanticipatethattheACSHealthPolicyandResearchInstitutealsowillprovidebright,youngpeoplewhoareinterestedinlegislativeandregulatoryissueswithafertiletraininggroundforexploringfresh,innovativeideasabouthowwe,asaprofessionandasanation,canimprovepatientcarethroughreasonedpolicydecisions.Theseprogramsforyoungthoughtleadersensurethatthisorganizationservesasatrue“college”forsurgeonsandisnotjustanotherprofessionalassociation.

Strong, coordinated presenceBecausetheinstitute’sstaffwillbeconducting

researchandhelpingtowritepositionstatementsonissuesaffectedbythefederalgovernment,theprogram’sheadquarterswillultimatelyrelocateto the building that will house the College’snewWashingtonOffice,which isscheduled forcompletionin2010.HavingtheCollege’sadvo-cacyandinstitutestaffsinthesamelocationwillallowforthetimelyexchangeofinformationandensurethatallofourpolicy-focusedeffortsarewellcoordinated.

AlthoughtheACSHealthPolicyandResearchInstitutewillbeheadquarteredinWashington,the institutewillmaintaina relationshipwithUNC.ThefactofthematteristhatourWashing-tonOfficewillnothavenearlythesameresearchcapabilitiesorstaffcapacityasourcollaborationwiththeShepsCenteraffordsus.

Establishmentof theACSHealthPolicyandResearchInstitutepresentsanopportunityfortheAmericanCollegeofSurgeonstoplayatrueleadershiproleinthehealthpolicyarena.Itwillenableustoserveasatrailblazerbycontributingrealandfactualdatauponwhichtobasesolu-tionstotheproblemsthathavebesetourhealthcaresystem.

NOVEMBER2008BULLETINOFTHEAMERICANCOLLEGEOFSURGEONS

5

If you have comments or suggestions about this orotherissues,[email protected].

Thomas R. Russell, MD, FACS

DatelineWashingtonprepared by the Division of Advocacy and Health Policy

OnSeptember11,theHouseWaysandMeansHealthSubcommitteeheldahearingonMedicare’sphysicianpayment system.Testimonyfocused on changes Congress should consider next year in order toavert the cut of more than 20 percent in Medicare reimbursementscheduledto takeeffect in2010.Witnesses includedtwo formerad-ministrators of the agency now known as the Centers for Medicare&MedicaidServices(CMS):BruceVladeck,PhD,andGailWilensky,PhD.Dr.VladeckexpressedsupportforreformssimilartothosethattheAmericanCollegeofSurgeonshasproposed,whichwouldreplacethecurrentsustainablegrowthrate(SGR)methodologywithareim-bursementformulacomposedofseparatespendingtargetsforspecifictypesofservices.Thisnewpaymentstructurewouldincludeadistinctcategoryformajorsurgicalproceduresand,consequently,sparesurgeryfrom the across-the-board, blunt payment cuts caused by the SGR.Dr.Wilenskyalsoexpressedinterestinthisproposal.Formoreinforma-tionregardingthishearing,gotohttp://waysandmeans.house.gov/hear-ings.asp?formmode=detail&hearing=645.

OnAugust29,theCollegesubmittedcommentstoCMSregardingtheproposedruleforthe2009Medicarephysicianfeeschedule.Theletteraddressesthefollowingprovisionsofconcerntosurgeons:arequire-mentthatphysicianswhofurnishdiagnostictestingservicesenrollasindependentdiagnostictestingfacilities,changestotheeffectivedateforMedicarebillingprivilegesforphysicians,anincentivepaymentandsharedsavingsprogram,andupdatestothePhysicianQualityReportingInitiative.Inaddition,theproposalcallsfordevelopingmeanstoaddresspotentially“misvalued”services.ToviewtheCollege’scomments,gotohttp://www.facs.org/ahp/views/medicare2009.html.

TheCollegesubmittedcommentsonSeptember2regardingtheout-patientprospectivepaymentsystemandambulatorysurgical center(OPPS/ASC)proposedrule.InthislettertoCMS,theCollegeaddressesthe following issues:aplan toextendpaymentpolicies forhospital-acquiredconditionstooutpatientsettings,aproposaltoaddimagingefficiencymeasuresusing2008Medicareadministrativeclaimsdata,andsuggestedchangestothelistofcoveredsurgicalproceduresdesignatedasdeviceintensive.Toviewthiscorrespondence,gotohttp://www.facs.org/ahp/views/ambulatory.html.

AnewCMSclaimadjustmentreasoncode(CARC#213)becomesef-fectiveJanuary1,2009,foruseindenyingclaimsthatarenoncompliantwiththeStarkself-referrallaw.Thislegislationprohibitsphysiciansfrom referring Medicare patients needing certain designated healthservices(DHS)tofacilities inwhichthephysiciansoranimmediatefamilymemberhaveafinancialrelationship.Penaltiesforviolationsofthelawincludedenialofpayment,refundofamountscollectedforDHSpayment,andcivilmonetaryfines.CARC#213isthefirstspecificcodetodescribeclaimsdenialsresultingfromviolationoftheStarklaw.Formoreinformation,gotohttp://www.cms.hhs.gov/transmittals/downloads/R1578CP.pdf.

House starts looking at payment reform options

ACS comments on fee schedule

ACS comments on OPPS/ASC proposed rule

New code for noncompliance with Stark law


7

found the following message one earlymorningwhenIopenedmye-mail:

Am a Ugandan mother of three boys, my lastborn sonwho is only sevenmonthsoldwas twoweeks ago diagnosed with a heart complication.ThedoctorsatMulagoHeartInstitutesayhehasaholebetweenthetwowallchambersoftheheartandontopofthatoneofthepulmonaryarteriesissonarrowthattheamountofbloodpumpedtothelungsisminimaltherebyaffectinghisbreathing.It’s sounfortunate that the condition cannotberectifiedhereinUganda.Ithoughtofcontactingyouincaseyoucanbeofhelptomesomyrequesttoyouistokindlyassistmewherepossibletosavethelifeofmysweetbaby.Anykindofassistanceishighlyappreciated.

And so began Fahad’s journeyFahadBukenyahadTetralogyofFallot.Atfive

monthsofage,hebegantoweakenandbecomelessactive.Hecontractedmalariaatsixmonthsofageandwasseeninhislocalhospital,wherehismurmurwasheard.HewasthenreferredtoKampala,thecapitalcityofUganda,whereattheMulagoHeartInstitutethediagnosiswasmadewithanechocardiogram.Hisaorticoverridewas40 percent, his parachlorophenylalanine was9mmwithconfluentbranchpulmonaryarteries.Noatrialsepticdefect,patentductusarteriosus,orcoarctationoftheaortawasseen,andtherewasnoVOTobstruction.

I have had the privilege of working withHeidiHessinTampa,FL,whocoordinatestheGiftofLifeprogramhererunbyRotaryInter-national. It is a program to help children whoareunabletohavecardiacsurgeryintheirowncountriesandhasservedsomanywithsuchgreatneed.Iknewthatthisbabymustbehelped,andIcontactedMs.Hessabouthim.

ItwasbelievedthatFahadwouldbeanexcel-lentcandidate forrepair,but that itshouldbedonequickly.St.Joseph’sHospitalinTampaandPaul Chai, MD, an extremely talented cardiac

surgeon, reviewed the information and agreedtotakehiscase.

JeanneHardin-Gres—anurseanesthetistandmygoodfriendandmentor—andIwereleavingfor Uganda in just three weeks to review anddiscuss the development of a medical complexthatwasbeingplannedforthevillageofPapoli.Ideally,Fahadandhismother,Anne,wouldtravelbackwithus,ifdetailscouldbeworkedout.

Icontactedatravelagentwho,amazingly,wasable to get seats for Fahad and his mother onthesameairlineflight.Myfriendandminister,Rev. John DeBevoise, at Palma Ceia Presbyte-rianChurch,wasabletoraisethefundsforthetickets forFahadandAnne.A letterwas thensent toAnne from theGift ofLifeprogramtohelpwithobtainingpassportsandvisasforherandherson.

Fahadcouldbarelyeat,hecouldnotsitup,andhedidnot smile,buthe lookedatpeoplewithenormouseyesthathadgreatpain.Eachbreathwasaneffort.Hisnailbedsandlipswereblue,andhealreadyhadclubbingofhisfingers.ThefirsttimeIsawhim,onadarkstreetinKampala,myheartbrokeandwasrebuilt…andIknewwemustmakethisjourney.

Annewas toldby theU.S.Embassy that thestaffwouldneedtotalktomebeforevisascouldbegranted.Soafteraweekinthebush,wetrav-eled on Friday morning to the capital to meetwithrepresentativesattheEmbassy.

I was told at the front gate again and againthat visas were not issued on Friday. I thenmetwitharepresentativeattheEmbassy,andIwastoldtherewouldbenoproblemobtainingthevisasthenextweek.Itoldhim,“Youdon’tunderstand—weareleavingtonight.Ifthisbabydoesnotcomewithus,hewilldie.Ifhecomeswith us, he will have his only chance for life.You must do something.” Four hours later, wewalkedoutoftheEmbassywithpassportsandvisas.Idonotknowhisname,butthismanwastrulyanangel.

The trip to TampaWeleftKampalaatmidnighttobeginthe24-

hour tripback toTampa.Westressed toAnnehowimportantitwasthatFahadnotcry,aswewereconcernedaboutatetspell,andwesedatedhimwithBenadrylasneeded.Hewassoweak

Opposite: left, top to bottom: Ms. Hardin-Gres, Dr.Campbell,Anne,andFahadinUgandacheckinginattheairport;AnneandFahadonthemorningofsurgery;Fahadonthenightofsurgery;postoperativedayone,recovering;AnneandFahadinDr.Campbell’sgarden.Opposite,right:Fahadonthenightofsurgery.

I


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thathedidnothavetheenergytocry,andthetripwasamazinglyuneventful.

However,onhispreoperativeappointmentatthehospital,hewasnotedtohaveasignificantthrombocytopenia,withhisplateletcountfallingto35,000.Healsowasnotedtodesaturatetoanoxygensaturationof19percentwhenhecried.Theselaboratoryvaluesnecessitatedaweekinthecardiacintensivecareunittodeterminethathe had idiopathic thrombocytopenic purpura,thoughttobesecondarytoaviral infectionhehad caught before leaving Uganda. All of hisotherworkup,includingabonemarrowanalysis,wasnegative.

Even with the low platelets, it was believedthathissurgerywascritical,ashecontinuedtodesaturateandweaken.

The operation and recoveryFahad was taken to the operating room on

March18,2008.There,Dr.Chaiwasabletodoanamazing job repairinghisheart.Hisdefectwasclosedandhisstenosisresected.Thetechni-calskillofDr.Chaiandhisteamwereevidentasthesurgeryprogressed.Fahad’sstenosiswasjustunderthevalve,andextremecarehadtobetakennottocauseinjurytothevalve.Hispost-repairintraoperativeechocardiogramshowedexcellentnormalflow,andhistinychestwasclosed.Hisheart,oncepurple,wasnowpink.

Fahad had an unremarkable recovery and

wasdischargedtomyhomeonGoodFriday.Hisplateletsremainedlowbutslowlyrespondedtosteroids. With the help of my dear friend IrisAlexander,themanagerofthecardiaccathlabo-ratory,anoutpouringofcommunitysupportwasorganizedforFahadandhismother.

Hefoundhisappetiteandbegantoeatevery-thinghecould,especiallymashedpotatoes.Heandhismotherbecamepartofmyownfamily,aswellastheextendedfamilyofourcommunitywheremyhusband,mychildren,andallwhomethimfellinlovewithhissmile.Hebegantosingandlaughallthetime,andwhenhereturnedtohishome,sixweekslater,hewasabletostand.Hegrabbedeverything,andwascuriousaboutallthosewhogavetheirsupportandwhocametovisit.

Fahad and Anne have returned to Uganda,whereheshouldhaveanormallife,alifefullofallthewonderandenergyofanylittleboy,forhisbrokenheartisnowfixed.

donotknowwhyFahadwasputinfrontofme.Idonotknowwhatthefuturewillholdforhim,norforhis

family.IdonotknowwhatGod’sgreaterplanmaybe.ButIdoknowthatinasmallvillageinAfrica,alittleboy

laughs,andsings,andafamilyhasbeenrestored,thankstothekindnessofthoseinacountryfaraway.

Thereismuchintheworldthatiswrong.Butthereisalsomuchwhichisright.Andbyreachingouttoachildinneed,amiraclehasbeen

sharedbothbythosewhohavegivenit,andthosewhohavereceivedit.

Andnoneofusarethesame.

—Sylvia D. Campbell, MD, FACS

Dr. Campbell is a general surgeon in private practice in Tampa, FL.

Dr.CampbellandFahad.

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ACS Practice Patterns Survey, Part II:

Prescribing habits among surgical sPecialties

by Charles M. BalCh, MD, FACS;and ThoMas r. russell, MD, FACS


11

Dr. Balch is professor of surgery, oncology, and dermatology at The Johns Hopkins School of Medicine, Baltimore, MD.

W ith the continued advances andwidespreadavailabilityofsafer,moreeffective drugs and other systemicagents, the surgeon of today is en-

gagedinamuchmoreholisticapproachtotreatthewholepatient.Indeed,surgeonsofallsurgi-calspecialtiesprescribemedicationsfrequentlyasan integralcomponentof theircare for thesurgicalpatient.

Until now, there were very little data thatshowedhowfrequentlysurgeonsprescribedrugsandwhichclassesofdrugswereusedwithineachofthesurgicalspecialties.Toaddressthisissue,anelectronicsurveyofACSmemberswasconductedin fall2007.Theresponseratewas impressive:4,207 individualsparticipated, representing thebroadrangeofpracticesettingsandsurgicalspe-cialties.Nearly45percentoftherespondentsworkinauniversity/teachinghospital,39percentareinprivatepractice,andtheremainderprovidescareinotherenvironments.Thelargestpercentageofrespondents(40percent)classifiedthemselvesasgeneralsurgeons,andtheother60percentrep-resentedthemajorityofsurgicalspecialties.Thebreakdown of surgical subspecialties was verysimilartothatoftheACSmembershipoverall.

Prescribing patternsThisstudy, the largesteverpublishedonthis

subject,clearlyindicatesthatsurgeonsinavarietyofsettingsandspecialtiescommonlyprescribeawide range of medications. The majority of re-spondents(80percent)saidthat,onaverage,theyortraineesworkingundertheirsupervisionpre-

scribemorethan10drugseachweek;56percentprescribemorethan20drugsperweek,and45percentprescribemorethan25inthecourseofaweek.Amongthesurgicalspecialties,thetopthreespecialtiesprescribing20ormoredrugseachweekwerespecialistsintrauma/criticalcare,urology,andotolaryngology–headandneck(seeFigure1,page13).Followingisalistofthepercentagesofsurgeonswithinspecificsurgicalspecialtieswhoissue20ormoreprescriptionsperweek:

• Trauma/criticalcare 90%• Urology 77• Otololaryngology–headand necksurgery 71• Cardiovascular 66• Colonandrectalsurgery 62• Vascularsurgery 62• Surgicaloncology 61• Generalsurgery 58• Pediatricsurgery 57• Plasticandmaxillofacialsurgery 35• Breastsurgery 25

Not surprisingly, most of these prescriptionsarefordrugsusedinperioperativecare,suchasanalgesics,antibiotics,andantiemetics.However,it is interesting to note that surgeons reportprescribingarangeofmedicinesforrespiratory,cardiovascular, gastrointestinal, critical care,and thrombosis conditions on a weekly basis(see Tables 1-3, page 14). Furthermore, half ofthestudyparticipantssaidthat,withinthepastyear,theyhaveorderedorprescribedarecentlyapproved therapy or one under investigation.Followingarethemostcommonclassesofdrugsprescribed,onaverage,forfiveormoreperweekbysurveyrespondents:

• Analgesics 78%• Antibiotics 66• Antiemetics 42• Antithrombosisagents 33• Anti-inflammatoryagents 38• Gastrointestinalagents 36• Anticoagulationagents 26• Cardiovascularagents 23• Diuretics 16• Respiratory 17• Hormones 7


12

Figure: Drug orDers by sPecialtyDrug Orders

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

General SurgeryOtolaryngology – Head and Neck SurgeryVascular SurgeryColon and Rectal SurgeryUrologyTrauma/Critical CareCardiothoracic SurgeryPediatric SurgeryPlastic and Maxillofacial SurgeryBreast SurgerySurgical Oncology

General Surgery 45.34% 13.15% 16.83% 12.27% 7.85% 2.62% 1.21% 0.74%

Otolaryngology – Head and Neck Surgery 60.00% 10.98% 13.73% 9.80% 2.35% 1.18% 0.78% 1.18%

Vascular Surgery 49.06% 12.74% 12.26% 13.21% 9.91% 2.36% 0.00% 0.47%

Colon and Rectal Surgery 45.50% 16.93% 17.99% 10.05% 4.76% 3.17% 0.53% 1.06%

Urology 65.12% 12.21% 14.53% 5.23% 2.33% 0.00% 0.58% 0.00%

Trauma/Critical Care 83.53% 6.47% 5.29% 1.76% 1.18% 0.59% 0.00% 1.18%

Cardiothoracic Surgery 55.69% 10.18% 11.98% 10.78% 7.19% 3.59% 0.60% 0.00%

Pediatric Surgery 46.63% 9.82% 15.95% 10.43% 13.50% 3.07% 0.61% 0.00%

Plastic and Maxillofacial Surgery 18.59% 16.03% 17.31% 24.36% 20.51% 3.21% 0.00% 0.00%

Breast Surgery 14.40% 10.40% 15.20% 22.40% 27.20% 10.40% 0.00% 0.00%

Surgical Oncology 48.78% 12.20% 13.01% 13.01% 8.94% 2.44% 1.63% 0.00%

More than 26 21-25 16-20 11-15 6-10 5 or less None (blank)

Count of specialty

drug orders per week

specialty

No response

Count of specialty


13

The di f ferent c lasses ofdrugs were prescribed withdifferent frequency amongthe surgical specialties. Fol-lowingisalistofsubspecial-ties with the most commonclassofdrugsprescribed(foraverageuseofmorethan10perweek):

•Analgesics Trauma/criticalcare 91% Generalsurgery 66 Pediatricsurgery 59 Colonandrectalsurgery 59 Cardiothoracicsurgery 59 Surgicaloncology 58 Vascularsurgery 54

• Antibiotics Trauma/criticalcare 78% Urology 72 Otolaryngology 53 Cardiovascular 40 Generalsurgery 39 Pediatricsurgery 39

• Antiemetics Trauma/criticalcare 49% Generalsurgery 31 Colonandrectalsurgery 21 Surgicaloncology 21

• Antithrombosis agents Trauma/criticalcare 49% Vascularsurgery 32

• Anti-inflammatory agents Trauma/criticalcare 37% Otolaryngology 21 Cardiothoracic 19 Urology 17 Pediatricsurgery 17 Surgicaloncology 14 Generalsurgery 14

• Gastrointestinal agents Trauma/criticalcare 43% Colonandrectalsurgery 24

Table 1: analgesics by sPecialty

>20 11-20 6-10 1-5 Never No

response

Breast Surgery 8.00% 22.40% 37.60% 30.40% 1.60% 0.00%

Cardiothoracic Surgery 31.74% 27.54% 25.15% 13.17% 1.20% 1.20%

Colon and Rectal Surgery 24.34% 34.39% 29.10% 11.11% 1.06% 0.00%

General Surgery 32.93% 33.74% 23.34% 8.58% 1.14% 0.27%

Otolaryngology– Head and Neck Surgery

10.20% 20.39% 40.78% 27.06% 1.18% 0.39%

Pediatric Surgery 33.74% 25.15% 26.99% 13.50% 0.61% 0.00%

Plastic and Maxillofacial Surgery

21.15% 23.08% 39.10% 16.03% 0.64% 0.00%

Surgical Oncology 31.71% 26.02% 25.20% 14.63% 2.44% 0.00%

Trauma/Critical Care 80.59% 10.59% 6.47% 2.35% 0.00% 0.00%

Urology 17.44% 26.16% 36.63% 18.60% 1.16% 0.00%

Vascular Surgery 27.83% 26.89% 30.19% 14.62% 0.47% 0.00%

table 2: antibiotics by sPecialty

>20 11-20 6-10 1-5 Never No

response

Breast Surgery 3.20% 6.40% 24.00% 64.00% 0.80% 1.60%



General Surgery 12.94% 25.96% 33.87% 25.82% 1.01% 0.40%


25.88% 27.45% 34.51% 1

1.76% 0.00% 0.39%



10.26% 21.15% 38.46% 30.13% 0.00% 0.00%



Urology 36.63% 34.88% 21.51% 6.98% 0.00% 0.00%

Vascular Surgery 8.96% 21.23% 36.32% 32.55% 0.47% 0.47%

Table 3: antiemetics by sPecialty

>20 11-20 6-10 1-5 Never No

response

Surgery 1.60% 3.20% 11.20% 54.40% 28.80% 0.80%



General Surgery 11.94% 19.25% 26.56% 37.29% 3.76% 1.21%


1.57% 3.53% 13.33% 60.78% 1

8.82% 1.96%



5.13% 8.97% 19.87% 53.21% 9.62% 3.21%



Urology 3.49% 4.65% 9.30% 63.37% 17.44% 1.74%

Vascular Surgery 3.30% 10.38% 18.87% 48.11% 17.45% 1.89% continued on next page


14

Dr. Russell is Executive Director of

the College in Chicago, IL.

Cardiothoracic 21 Generalsurgery 20 Otolaryngology 20 Surgicaloncology 15

• Cardiovascular agents Cardiothoracic 51% Trauma/criticalcare 42 Vascular 30 Generalsurgery 12

• Diuretics Cardiothoracic 39% Trauma/criticalcare 20

• Respiratory Trauma/criticalcare 38% Cardiothoracic 23

• Hormones Urology 20% Breastsurgery 6

Within surgical specialties, therewerevary-ingprescribingpatternsaswell.For example,trauma/critical care specialists prescribed theentire range of drugs classes, but the natureof theirpatient carecaused themtomost fre-quently prescribe analgesics (91 percent pre-scribe10ormore/week),antibiotics(78percent),antiemetics (49 percent), and antithrombosisagents (49 percent). General surgeons mostfrequently prescribed analgesics (66 percent),antibiotics (39 percent), antiemetics (31 per-cent),andgastrointestinalagents(20percent).Urologistsmostfrequentlyprescribedantibioticsandhormones.

Thedatainthissurveydidnotpresentasuf-ficientsamplesizetoassesstheuseofsystemiccancer agents. However, a similar survey wasconductedin2006amongmembersoftheSoci-etyofSurgicalOncology.Withinthisspecialty,theuseofsystemicagents forcancermanage-ment would be prescribed more frequently asa component of the multidisciplinary cancermanagement. Thus, among the 532 surgicaloncologyrespondents,two-thirdseachweekei-*BalchCM.Prescribingpatternsofsurgicaloncologists:Arewesurgeons,oncologists,orboth?Resultsofasocietyofsurgicaloncologysurvey.Ann Surg Oncol.2007;14:2685-2686.

therprescribed,recommended,oradministeredoncology-related hormone agents. In addition,30percentdidsoforchemotherapeuticagentsandgrowthfactors,and21percentprescribedmonoclonalantibodies.*

Conclusion Thesedataprovidenewinsightsintotheprac-

ticehabitsofsurgeonscaringfortheirpatients.Thereweredifferencesinboththetypesofdrugsused and the frequency of prescribing themamong the various surgical specialties. Mostnotablewasthehighfrequencywithwhichallsurgeonsprescribedvariousdrugsandsystemicagentsinthedailycareoftheirpatients.


15

thesewoundedtroops.EverySVShasdescribedthiscareasbeingoutstanding.

ThemedicalpersonnelatLRMC—consistingofmembersoftheU.S.Army,Navy,andAirForce—facechallengesunlikethoseatanyothertraumacenter.First,theinjuriesbeinginflictedonourtroopsarecomplexandofextremelyhighacuity.Thetypicalinjurypatternfollowsanexplosionandmayconsistofblast,burn,blunt,andpen-etratinginjuriescombined.Notuncommonly,theinjuredtroophasundergoneoneortwooperativeproceduresbeforearrivinginGermany,includingvascularshuntingfollowedbydefinitivevascularrepair,damagecontrollaparotomies,decompres-sivecraniotomies,andstabilizationoffracturesortheinitialphaseoffluidresuscitationforburnwounds.Mostofthesepatientsleavethecombattheaterhospitalwithin24to48hoursoftheirinjury,flyingeighthourstolandatRamsteinAirForce Base in Germany, a short distance fromLRMC.Thepatientsarrivetogetherinbusloadsandaretriagedtoeithersurgicalwardsortheintensivecareunit.Itisnotuncommontoreceivefivetosevencriticallyinjuredpatientssimultane-ouslyatLRMC.Fortunately,viatheWeb-basedJointPatientTrackingApplication,thedataonthesepatients(includingoperativenotes,com-putedtomography[CT]scans,andsoon)canbereviewedlongbeforetheirarrival.

OnceinGermany,thewoundedtroopsundergoareevaluationofallinjuries.Invasivelinesarechanged and laboratory values rechecked, andmany undergo additional surgical proceduressuchasclosureofabdominalwounds,burnorsofttissuewounddebridements,musclecompartmentreleasesifneeded,andmoredefinitivetreatmentoffractures.Scanningfordeepvenousthrombo-sis(orpulmonaryemboli)isahighpriority.Stepsaretakentoidentifyandcontrolinfectionsandemphasisisplacedontheprovisionofadequatenutrition. Anxious families are contacted andupdatedastotheconditionoftheirlovedonesarrivinginGermany.Alloftheseactivitiesaredoneonastricttimeline,withthegoaloftrans-porting stabilized patients to the continentalU.S.—to Walter Reed Army Medical Center;NationalNavalMedicalCenterinBethesda,MD;orBrookeArmyMedicalCenterinSanAntonio,TX—assoonasfeasible(typically24to48hourslater).Asthisnextphaseoftransportinvolves

Thehistoryoftraumaparallelsthehistoryofwar,andthereisnodoubtthatmanyoftheprinciplesthatguidetraumacarearebeingrewrittenduringtheongoing

globalwaronterrorismcurrentlybeingwagedinIraqandAfghanistan.Infact,thisconflicthasthelowestoverallcasefatalityrateofanywarinU.S.history.Thisoutcomeistrulyremarkable,consideringthatthecaregiventothesewoundedtroopsspansthreedifferentcontinents.Inordertobetterappreciatetheseadvancesinmilitarymedicine,theleadershipoftheAmericanCollegeofSurgeonsCommitteeonTrauma(COT)andoftheAmericanAssociationfortheSurgeryofTrauma,working in conjunctionwith theU.S.military,developedtheSeniorVisitingSurgeons(SVS)program.

The global objective of this program is toestablishscientificexchangebetweenthe lead-ersinciviliantraumacareandourexperiencedmilitarycounterparts.TheSVSprogramisalsomeanttorapidlyforwardthelessonslearnedinthemilitaryrealmtotheciviliansector.Todate,theSVSeffortshavebeencenteredatthelarg-est U.S. military medical center outside of thecountry’sborders:LandstuhlRegionalMedicalCenter(LRMC)inLandstuhl,Germany.LRMCis the receiving hospital for all injured troopsbeingevacuatedfromIraqandAfghanistanandthe laststop for thesepatientsbefore transferbacktotheU.S.

TheSVSprogram,whichwasinitiatedin2006,involvesatwo-tofour-weekrotationatLRMCaspartofparticipants’trauma/criticalcareser-vice. The civilian surgeons rotating at LRMChaveprovidedscientificseminars,givensurgicalgrandrounds,instigatedormentoredscientificresearch,assistedinpreparingfortraumacenterverification,attendedthepeerreviewconferences(which also span three continents), and, mostimportantly, were privileged to participate inthesurgicalandcriticalcarebeingrenderedto

Opposite, top photo: Helicopter landing outside theemergencydepartment,bringinginjuredpatients. Center: “Heroes Highway” (left to right): JoshuaAlley,MD;Col.JayJohannigman,MD,FACS;ColonelJenkins;Dr.Knudson;ToddRasmussen,MD,FACS;andCarlBaker,MD. Bottom:Dr.Knudsonparticipating inside-by-sidecraniotomiesintheoperatingroomofthe332nd.


17

atleast12hoursinflight(18hourstoBrooke),thereisnoroomforerror,andadequateprepara-tionofeachpatientbeforetransportisadictum.Everylaboratoryvalue,line,tube,andmonitormustbecorrected,secured,andaccuratebeforeleavingLRMC.

Despite all of these challenges, the remark-able care rendered at LRMC is delivered withthehighestprofessionalismandwiththedeep-estcompassion.Indeed,thiswasreaffirmedbymembers of theACS/COTVerificationReviewCommittee who recently verified that LRMCmet(andoftenexceeded)allofthecriteriaforalevelIItraumacenterasdefinedbytheCOT.*(The observations of some of the SVSs whileatLandstuhlhavebeenpublishedintwopeer-reviewedarticles†).FollowingtheleadoftheSVSprogram, civilian neurosurgeons, orthopaedicsurgeons,andvascularsurgeonshavealsovol-unteeredtheirservicesatLRMC.

Although the experience at Landstuhl wasboth educational and fulfilling for the civiliansurgeons,manyofusfeltthatweweremissingthe “front end” of care being delivered in thecombat zone. We wanted to understand morefullythechallengesofworkingincombatsup-porthospitalsandgainexperienceintheinitialtreatmentoftheseoftendevastatinginjuries.IwasrecentlyofferedtheincredibleopportunitytovisittheAirForce’s332ndAirExpeditionaryWing(AEW)TheaterHospitallocatedatBaladAirBaseinIraq.WhileIpreparedforthisad-venture, I formulated the following list of myobjectivesfortakingthisstep:

1. Toassistincodifyingtheimportanttraumasurgical lessons learned during the currentconflict in order to preserve them for futureconflicts

2. Toidentifyareasthatmightbenefitfromcollaborative research involving both militaryandciviliantraumaresearchgroups

3. Toprovideconsultationforthecontinueddevelopmentofthemilitarytraumasystem

4. TofostertheeducationalprocessneededtotranslatethelessonslearnedinOperationIraqiFreedomandOperationEnduringFreedomtocivilian trauma care both for daily use and inpreparationformasscasualtiesanddisasters

5. To explore the potential development ofprograms whereby civilian trauma surgeonsmightprovideassistancetoourmilitarysurgicalcolleagues

2008 Joint Theater Conference

OneoftheinitialgoalsofourmissiontoIraqwastoparticipateintheJointTheaterTraumaSystem [JTTS] Chief Conference, The Con-tinuum of Trauma Care in the Matured U.S.Central Command/European Command AreasofResponsibility.Iwashonoredtobeaccompa-niedontheentiretripbyCol.DonaldJenkins(USAF), MD, FACS, who met me in Germany,assured that I got through all checkpoints enroute to Iraq, and attended to my security ateverylevel.Wewerebothinvitedtopresentat

Recent publications describing military treatment modalities

• ChungKK,BlackbourneLH,WolfSB,etal.EvolutionofburnresuscitationinOperationIraqiFreedom.J Burn Care Res. 2006;27:606-611.

• SchreiberMA,PerkinsJ,KiralyL,etal.Earlypredictorsofmassivetransfusionincombatcasual-ties.J Am Coll Surg. 2007;205:541-545.

• SpinellaPC,PerkinsJG,McLaughlinDF, etal.TheeffectofrecombinantactivatedfactorVIIonmortalityincombat-relatedcasualtieswithse-veretraumaandmassivetransfusion.J Trauma. 2008;64:286-294.

• Holcomb JB. Damage control resuscitation.J Trauma. 2007;62:S36-S37.

• RasmussenTE,ClouseWD,PeckMA,etal.Developmentandimplementationofendovascularcapabilities inwartime.J Trauma. 2008;64:1169-1176.

• HolcombJB,ChampionHR,PruittBA,etal.Advancesincombatcasualtycare:Clinicaloutcomesfromtheway.J Trauma. 2008;64(suppl):S1-S205.

*KnudsonMM,MitchellFL,JohannigmanJA.Firsttraumaverification review committee site visit outside the U.S.:LandsthulRegionalMedicalCenter,Germany.Bull Am Coll Surg. 2007;92:16-19. †Moore EE, Knudson MM, Schwab CW, Trunkey DD,JohannigmanJJ,HolcombJB:Military-civiliancollaborationin trauma care and the senior visiting surgeon program.New Engl J Med. 2007;357:2723-2727; and Trunkey DD,JohannigmanJA,HolbombJB.Lessonsrelearned.Arch Surg.2008;143:112-114.


18

this inaugural traumaconfer-ence,facilitatedbyCol.GeorgeCostanzo(USAF),whowasatthattimeservingasthedirec-toroftheJTTS.Surgeonsfromthe various echelons of care,fromfarforwardsurgicalunitstothecombatsupporthospitalsthroughoutIraq,attendedtheconferenceandpresentedtheirexperienceintreatingvariousinjuries and the challenges ofdealingwiththeebbandflowofpatientcaredemands.Thefor-maleducationalportionoftheconference highlighted someofthedevelopmentsincombatcasualty care that are clearlycontributing to the low fatal-ityrateinthiswar.Althoughadiscussion of these treatmentmodalitiesisbeyondthescopeof this article, they are welldescribedinrecentpublications(seeboxed item,page18)andcanbesummarizedasfollows:

• Screeningforsymptomsofminimalbraininjuryinallinjuredtroops

• Redesignofpersonalprotectivegear

The JTTS

Care of the injured in Iraq and Afghanistanbeginsatthesiteofwoundingwithself-aidandbuddy care. Further care in the field may berenderedbythecombatmedicasdictatedbytheguidelines promulgated by the Committee forTacticalCombatCasualtyCare.Whenappropri-ate,orifnearby,thecasualtymaybemovedtoaforwardoperatingbaseandthebattalionaidstation (Level II), where field medics initiateadditional first aid for the wounded. Forwardsurgical teams are located in many locationsthroughout the theater and are designated aslevel IIB facilities, capable of conducting lifeand limb stabilization in far-forward and aus-tereconditions.Thepatientisthentransferredvia helicopter to the combat surgical supporthospitals (Balad and Baghdad in Iraq). ThesefacilitiesaredesignatedaslevelIIIfacilitiesand

• Reneweduseand redesignof tourniquetsthatcanbeself-applied

• Useofinnovativehemostaticdressingsforopenwounds

• Adoptionofamassivetransfusionprotocolthatadvocatesformoreliberaluseoffreshlyfro-zenplasmaandplateletsalongwithpackedredcells(so-calleddamagecontrolresuscitation)

• Use of point-of-care thromboelastogramresultstoguidetransfusionpractice

• Recognitionoftheadvantagesofusingfreshwholeblood

• Use of the procoagulant-activated factorVIIearlyinpatientsrequiringmassivetransfu-sions

• Aggressiveuseofvascularshuntsfortem-porarycontrolofvascularinjuries

• Development of endovascular capabilitiesincombatsupporthospitals

• Guidance of burn resuscitation using astandardizedclinicalpracticeguidelinealgorithmthattravelswiththepatient

• Adoptionofdamagecontrolstrategies forabdominal,vascular,andorthopaedicinjuries

Figure


19

have more complete surgical teams, includingsurgicalspecialistsandintensivecareunit(ICU)facilities. The current level III centers in thetheatermayberoughlyequatedascivilianlevelIItraumacentersintheU.S.Thesurgicalcareatthecombatsupporthospitalsisintendedtobemoredefinitive.Followingstabilizationwithinthe theater, the patients are evacuated to thelevelIVfacilityatLRMCviatheAirForceaero-medicalevacuationsystem.ThelevelVfacilitiesare themilitary trauma receivinghospitals intheU.S(seeFigure,page19).

Thiscomplextraumasystemiscoordinatedbyanumber ofmeasures.Leadership is providedbytheJTTSdirector,whooverseesallechelonsof care throughout Iraq and Afghanistan. Thesecondimportantcomponentisthejointpatienttracking application, the Web-based systemallowing entry of patient data at each level ofcare.Therearealsotraumaprogrammanagersatvarious locations inthetheatersystemwhosupplytheinitialentries intothe jointtheatertraumaregistry,arobusttraumadatabasethatnowcontainsdataonseveralthousandinjuredtroopsandintowhichdataareenteredateachlevelofcare.Researchpersonnelhavealsobeendeployedintotheaterhospitals.Theverytimelyperformanceimprovementprocessisfacilitatedby the weekly clinical video teleconference,which connects the military medical units inIraq and Afghanistan by audio to LRMC andWalterReedand to theU.S.Army facilities inSan Antonio (audio and visual) during whichindividualpatientsarediscussedandtheircarereviewed at every level. This coordinated pro-cess has also resulted in the development of anumber of trauma clinical practice guidelinesthatareconsideredstandardsofcarewithinthetheater trauma system, including prophylaxisfor venous thromboembolic complications, an-tibioticuse,preventionofhypothermia,andthemanagementofspecificinjuriessuchasburns,vasculartrauma,andtraumaticbraininjuries.‡Thishighlyfunctionaltraumasystemistrulyre-markablewhenoneconsidersthatitwaslargelydevelopedandrefinedduringthewar.

The trauma experience at Balad

Duringthesecondpartofmyvisit,Iwasabletointegratemyselfintothesurgicalteamandpar-ticipateasmuchaspossibleinpatientcareandintheoperatingroomatthe332ndAEWhospital.ThishospitalservesnotonlyasalevelIIIcombatsupportfacilitybutalsoastheprimarycollectionpointforcasualtiesrequiringevacuationoutoftheater.Theinitialconfigurationofthehospitalconsistedofmorethan30interlinkedtents,butin2007,the332ndmovedintoanewfixedfacility(seephotos,page21).Thehospitalconsistsofanemergencydepartment,fouroperatingrooms,anICU,andalargesurgicalward(seephotos,pages22-23).Therearealsolimitedoutpatientfacili-ties,awell-stockedbloodblank,advancedimag-ing capabilities, and a clinical laboratory. Themajorityofpatientsarrivebyhelicopters thatland just outside the emergency department.From the desk in the emergency department,onecanstandandseetheentireroomandob-serveallactivities,whichisanadvantageduringmasscausalitysituations.Theweekbeforemyarrival,thehospitalreceived32casualtiesdur-ingthecourseof90minutes,victimsofasuicidebomber in a market. The teams divide them-selvesefficientlyamongthecasualties,bloodandplasmaisdeliveredpromptly,laboratoryresultsarebackwithinminutes,andultrasoundunitsforFAST(FocusedAssessmentbySonographyinTrauma)examsarereadilyavailable.TherearetwomultidetectorCTscannersjustoffthemainroomandimmediatelyavailable,asistheradiologist.

Thesurgicalteamatthetimeofmyvisitcon-sistedofeightgeneralsurgeons (twoofwhomwerealsovascularsurgeonsandtwotrainedtho-racicsurgeons),twoorthopaedicsurgeons,twooral-maxillofacialsurgeons,twoneurosurgeons,oneear-nose-throatsurgeon,oneurologist,andtwoophthalmologists.Theteamissupplementedbyemergencyphysicians, internists,physicianassistants,nurses,andanesthesiologists.Therearefouroperatingroomsthatarefullystaffedsevendaysaweek.A“normal”daily scheduleconsistsof somewherebetween12to15semi-electivecasesonpatientsalreadyinthehospi-tal;however,roomsarealwaysreadytoprovideimmediatecaretotheincominginjuredandit

‡EastridgeBJ,JenkinsD,FlahertyS,etal.Traumasystemdevelopmentinatheaterofwar:ExperiencesfromOperationIraqiFreedomandOperationEnduringFreedom.J Trauma. 2006;61:1366-1373.


20

The original 332nd as a series of tents (top), and the newer hospital with Kevlar protective roof over a solidstructure.


21

isnotunusualtohavetwopatientsbeingoper-ateduponsimultaneouslyinthesameoperatingroomtheater.

TheICUisanopenunitwithbedsseparatedonly by curtains. Most of the patients in theICU are host nationals (Iraqi civilians, Iraqimilitary,contractors,andsoon).TheU.S.troopsare evacuated to LRMC in Germany usuallywithin24hoursof theirarrival if theircondi-tionpermits(seephoto,page24).ThisopenICUpresentsmultiplechallenges,includingtheneedtomeetthecareofmen,women,andchildrenalike.Thedifficultiesinmaintainingprecautionsagainstnosocomialinfectionsareevidentwhenwalkingthroughsuchabusyfacilitylocatedinthemiddleofanaustereandwarmenvironment.Anadditional clinical challenge is the stateof

malnourishmentofmanyIraqipatients,affect-ingtheirabilitytohealtheselarge,high-energycombat wounds. Provision of total parenteralnutritionislimitedbysevereinfectiouscompli-cationsandtheuseofenteralnutritionisoftenlimitedbyopenabdomens, enteric fistulae, orintra-abdominalinfections.Anadditionalchal-lengefacedbythemilitarymedicsistheprovi-sion of ongoing care for the patients who areIraqinationals.ThecurrentstateofthemedicalcareinIraqisveryaustereandlimitedeveninthe most rudimentary components of healthcare.Thisbecamemostapparentintheprocessof discharge planning, as the military medicsattempted to return their Iraqi patients intoahealthcare systemvastlydifferent than thestandardsmostU.S.physiciansareaccustomed

Entrancetotheemergencydepartmentatthe332nd.


22

to.Sadly,themediahavedirectedlittleattentiontothehumanitariansideofthemissionintheMiddleEast,especiallybyourdeployedmedicalpersonnel.

On my first day on-call, we received severalciviliansinjuredbygunfire.Twowereveryyoungchildrenwhohadsustainedgunshotwoundstothehead.Theywereexamined,intubated,andhad linesestablishedandCTscansperformed(andreadbytheradiologistandtheneurosur-geons), and both children were taken to theoperating room where two craniotomies wereinitiated side by side by two neurosurgeonswithin20minutesofarrival.MostU.S.traumacenters would find this scenario very difficulttoreplicate.

DuringmyshortstayinBalad,inadditiontoa craniotomy, I participated in several wounddebridements,abdominalreexplorations,fasci-otomies, vascular repairs, amputations, and athoracotomy. The wounds encountered in thiscombatenvironmentaresignificantlydifferentthanthosecommoninciviliantraumacare.Themajorityof injuriesarerelatedtoeitherhigh-energymissilewounds(AK-17,M-16)ortoblastinjuries (improvised explosive device, mortarrounds,explosiveformedprojectiles,andsoon).

Theextentandscopeofinjuriesnormallyincludemultiplesites,softtissueaswellasorthopaedicinjuries,oftenwithconcomitantvascularcom-promise.Theappropriatetraumaevaluationofthesepatientsincludesathoroughexaminationofallareasofthebodyandmusttakeintoconsid-erationbothbluntandpenetratingmechanismsofforcetransmission.Thevarietyandthesizeof objects removed from wounds as the resultofexplosivedevicesareunlikeanythingseeninourcountry.

My last day at the 332nd was the hardest.A U.S. soldier was brought in with four tour-niquets in place after a devastating explosiveinjury.Hewasinprofoundshockandtakendi-rectlytotheoperatingroomwherefoursurgicalteamsassembledaroundhisfourlimbsaswellashisneck,wherehehadanobviouspenetratinginjury.Unfortunately,thepatientexpired(oneofthefewdeathsinthisoperatingroom,whichisremarkableinitself).NearlytheentirehospitalstaffimmediatelyassembledforprayersandforthedrapingoftheAmericanflagoverhisbody(Patriot’sDetail).Thatnight,allthesurgeonsinvolvedinthiscasemetinthe“lounge”ontherooftopofthehospital(affectionatelyreferredtoas“OR#5”)anddiscussedthecaseandwhat

Theemergencydepartmentatthe332nd.


23

might have been done differently. This wastrulyauniquemortalityconferenceand,takentogetherwiththeweeklyvideo-teleconferencedescribedpreviouslyinthisarticle,canserveasanexcellentmodelforciviliantraumacen-ters.

CCATTs: Critical care in the air

Anotheruniqueexperiencewasmyabilitytoobserve the transport of injured troops fromIraqtoLandstuhlandthenfromLandstuhl toAndrewsAirBaseunderthecareoftheAirForceCritical Care Air Transport Teams (CCATT).Thetransportofcriticallyillpatientsandallthe

needed equipment—includingventilators, pumps, medica-tions,nutrition,monitors,andso forth—is an art in itself,andloadingitallintothebackof these huge cargo planeswithoutincidentinthedarkofnightinthemiddleofthedes-ert is like a well-orchestrateddance.Patientswithlesssevereinjuries (typically heading forwardcareatLRMCorWalterReed) are loaded first, to beattendedbynursesandmedi-cal technicians. (Theseplanescan transport as many as 50patients at a time.) The backoftheplaneisreservedfortheintensive care patients, eachof whom has his or her ownCCATTteam.Eachteamcon-sistsofacriticalcarephysician(surgeon,emergencyphysician,anesthesiologist, cardiologist,and so on), an ICU-qualifiednurse,andarespiratorythera-pist. During the flight, bloodgases are monitored, as areelectrolytesusingpoint-of-caretechnology;nutritionalsupportiscontinued;andnarcoticsandsedatives are administered asneeded.Theplane iscoldandnoisy,andthemonitoralarmsmust be visible because they

cannotbeheardabovethebackgroundnoiseofthe jet engines. Despite these challenges, thisICU in the air is highly effective and has pro-vided safe transport for stabilized (thoughnotnecessarilystable)criticallyinjuredtroopswiththegoalofgettingthembacktotheU.S.assoonaspossible.Itservesasanexcellentmodelofanevacuationprocessthatmightbeusedduringanaturalorman-madedisaster.

Directives for ACS Fellows

For the Fellows of the American College ofSurgeonswhoarenot currentmembersof themilitary,whatcanwedotoprovidesupportand

TheflightlinewhereinjuredpatientsareloadedfortransporttoGermany.


24

Dr. Knudson is profes-sor of surgery, Univer-

sity of California– San Francisco, and

Vice-Chair of the ACS Committee on Trauma.

assistancetoourdeployedmilitarycolleagues?Iwouldsubmitthefollowingdirectives:

1. Weneedtocriticallyandscientificallyevalu-atethelessonslearnedbythemilitarysurgeonsduringthisconflictandbecognizantofsituationswhere we can apply them in civilian traumacare.

2. Asmanyoftheseniormilitarysurgeonswillbeseparatedfromtheirrespectivemilitarypostsbeforethenextconflict,wemustassistthemindeveloping a “repository” for these importantlessons,sothattheycanbepassedontothenextgenerationofmilitarymedics.

3. Weshouldcontinuetoworkwiththemili-tarytowardthegoalofdevelopingaworldwidemilitary trauma system, using the ACS COTVerificationandSystemsConsultationCommit-tees.

4. We should consider innovative programsthatwouldallow civilian surgeons tofill postsnow occupied by military physicians. For ex-ample,civiliansurgeonscouldworkatVeteransAffairsHospitals,militaryhospitalsintheU.S.,or (after proper training) fly CCATT missionsfromLRMCtoAndrewsinordertorelieveourmilitarycolleagues.Perhapsthesenondeployablepositionscouldbefilledbyrecentgraduatesofsurgicalandspecialtyresidencyprogramsasamethodofpayingbackmedicalschooldebt.

5. Finally,wehaveanobligationtoassist inthehumanitarianmedicaleffortsinastabilizedMiddleEast.

Honor and privilegeIthasbeenadistincthonorandaprivilege

formetohavebeengivensuchanup-closeandpersonalviewofthishighlyorganizedandsuc-cessfultraumacaresystemputinplacebytheU.S.military.ForthosereaderswhohavelovedonesdeployedinIraqorAfghanistan,beassuredthat,shouldtheybe injured, theywillreceivetraumacarethatisunsurpassedbyanytraumasystemhereintheU.S.MytimeatLRMCandat the 332nd have been life-changing for me,bothpersonallyandprofessionally, and I lookforward to a continued association with mymilitarycolleaguesasweworktogethertowardestablishmentofaworldwidemilitarytraumasystem.Fornomatterwhatyourviewsareonthiswaroranywar,weoweourbravesoldiers,

airmen, sailors, and marines the very besttrauma care that we can deliver. In addition,weowe thepatients inour traumacentersathomethechancetobenefitfromthescientificdiscoveriescomingoutofthisconflict—thatis,afterall,ourobligationassurgeons.

Acknowledgments

IowespecialthankstothosewhofacilitatedmytriptoIraq,includingCol.BryanFunke;Col.JayJohan-nigman,MD,FACS;Col.DonaldJenkins,MD,FACS;Col.BryanGamble;Col.GeorgeCostanzo;andCol.LeePayne.IwouldalsoliketoacknowledgethemembersoftheBaladAssociationofDoctorsAnacondaSurgicalSocietywhoaresuperbsurgeons,dedicatedphysicians,andexemplaryindividuals.

Itwasaprivilegetoworkwitheveryone,includingDr.Johannigman;JoshuaAlley,MD;CarlBaker,MD;NabilHabib,MD,FACS;SolonHughes,MD,FACS;ToddRasmussen,MD,FACS;JaySampson,MD,FACS;andScottDavidson,MD.


25

TheStateAffairsareaoftheCollege’sDivisionofAdvocacyandHealthPolicyisresponsibleformonitoringandtrack-inglegislationatthestatelevel.FromJanuarytoAugust2008,morethan85,000billshadbeenintroducedinstate

legislatures across the country; this is approximately half thenumberofbillsintroducedbythistimelastyear.Thisdifferenceexists, in largepart,because2008 isanelectionyear.Electionyears, especially presidential election years, are traditionally“slower,”legislativelyspeaking.

Because therearesomanybillswithsomanyhealth-relatedtopics introduced in state legislatures, it is important to focustheCollege’sStateAffairsresources.Thisyear,theHealthPolicySteeringCommitteedirectedStateAffairstofocusonthefollow-ingfiveprimaryissues:

• Medicalliabilityreform• Trauma• UniformAccidentandPolicyProvisionRepeal(UPPL)• TheUniformEmergencyVolunteerHealthPractitionersAct

(UEVHPA)• ScopeofpracticeissuesHowever, there are issues beyond these categories that are

broughttotheattentionofStateAffairsbyindividualsurgeons

by Melinda Baker, State Affairs Associate,

Division of Advocacy and Health Policy

statelegislative

activity

or chaptersof theCollege. Inthosecases,staffmayprovideadvice and resources on thebestwaytodealwiththestatelegislationorregulationunderconsideration. These issuesincludehealthsystemreform,provider taxes, office-basedsurgery/ambulatory surgeryregulation, imaging restric-tions, licensure/maintenanceoflicensure,andlasersurgeryregulation,amongothers.

During 2008, State Affairsmonitoredmorethan145billsin35statesthroughuseofanonline legislative and regula-torysearchservice.Thefollow-ing bills are a representativesampleofthetypesoflegisla-tionthatwasmonitored.

Medical liability reform

Becauseofanumberof fac-tors, the last few years haveseen a significant decrease inthenumberofbillsdealingwithlarge-scale reforms related totheMedicalInjuryCompensa-tionReformAct.Thedecreaseislargelytheresultofthecaponnoneconomicdamagesthatnow exists in more than 30statesandbecausemanystateshaveenactedothersignificantreforms. The states withoutreformshavepoliticalclimatesthat are unfavorable to thistypeoflegislationorconstitu-tionalbarriers.Onceagainthisyear,mostofthelegislationre-latedtoliabilitywasdefensive,withmanyofthesebattlestak-ingplacenotatthestatehousebutinthecourts.

One state that has contin-ued to fight for a legislativesolutiontoitsliabilitycrisisisTennessee.Thisyear,Tennes-


26

seepassedS.B.2001/H.B.1993.Thesebillswereintroducedin2007andweresignedbyGov.PhilBredesen(D)inMay2008;theywillgointoeffectOctober1,2008.

Thebillsoriginallyincludedreformssuchasa$250,000stackedcaponnoneconomicdamages(maximum $500,000, with $250,000 for physi-cians and $250,000 for facilities per incident);a sliding scale for attorneys’ fees; affidavit ofmerit requirements; and periodic payment fordamagesexceeding$75,000.Allofthesereformsweredeletedfromthebill,whichwasamendedandpassed to include only the requirement ofaCertificateofGoodFaithbeforeaclaimmaybefiled(and60daysnoticebeforetheclaimisfiled) and to provide for sanctions against anyattorney found to be violating the notion of a“goodfaith”case.

Illustratingtheroleofthejudiciaryinmedicalliabilityreform,thecapsondamagesestablishedinIllinoisandGeorgiaarebeingchallenged inthecourts.

In Georgia, a state court ruled that the$350,000caponnoneconomicdamages(passedin2005)violatesthestate’sequalprotectionprin-ciples. TheGeorgiaSupremeCourthasagreedtohearthecase,althoughnohearingdatehadbeen set atpress time (Parks v. Wellstar, Case #2007CV135208).

Acasechallengingthe$500,000capinIllinoisiscurrentlybeingheardinthestate’sSupremeCourt.Inthiscase,aCookCountyCircuitCourtoriginallyruledinNovember2007thatthecapwasunconstitutionalbecauseitviolatedthesepa-rationofpowersclause.Arulingisnotexpectedinthiscaseuntilatleastthemiddleofthismonth

(Lebron v. Gottlieb Memorial Hospital).Although caps are not at issue in this case,

a very important battle is being fought in theFloridacourtsystem.InNovember2004,Floridavoterspassedseveralconstitutionalamendments.AmendmentSeven(alsoknownasthe“Patient’sRighttoKnowaboutAdverseMedicalIncidents”)allowedforopenmedicalrecordsandrequiredthereleaseofrecordsrelatedtoanyadverseincidentsthatcouldhaveledtopatientharm.Becauseofconcernsthatthisamendmentmightviolatethefederal Health Insurance Portability and Ac-countability Act (HIPAA) and adversely affectthepeerreviewprocess,theFloridalegislature

passedS.B.938in2005.Thisbillplacedrestric-tionsonwho couldview the recordsandwhatinformationtherecordswouldcontaininordertocomplywithHIPAA,whilestillallowing forpeerreview.ThelegislaturealsodeterminedthattheamendmentdidnotapplytorecordscreatedorincidentsoccurringbeforeAmendmentSevenwasadopted.

TheFloridaSupremeCourtrecentlyissuedanopinionontwocasesinvolvingAmendmentSevenandthesubsequentclean-uplanguageincludedin S.B. 938. The court ruled that AmendmentSeven is self-executing and retroactive and itsprovisions apply to records existing before itspassage. Essentially this ruling makes any in-formation—eveninformationdocumentedbeforethebill’spassage—notonlydiscoverablebutalsoadmissibleincourt.

TheFloridaChapteroftheCollegeisworkingwithothermembersoftheFloridamedicalcom-munity on this matter. (To read the full courtopinion, visit http://www.floridasupremecourt.org/decisions/2008/sc06-688.pdf.)

Trauma

System developmentTwomorestates,KentuckyandSouthDakota,

passedlegislationthisyearthatcreatesalegisla-tivelyrecognized“traumasystem.”

In mid-March 2008, South Dakota’s Gov. M.Michael Rounds (R) signed S.B. 200, which es-tablishesastatewidetraumanetwork.Thisleg-islationdirectstheDepartmentofPublicHealth,along with the Department of Public Safety, todevelop, implement, and administer a traumacare system. The Department of Public Healthisstillworkingontherules,andpublichearingswill beheldonce thedraft rulesarepublished.Thelegislationmandatesthattherulesincludethefollowing:1

• Designationofthelevelsoftraumahospitalsandtheresourceseachhospitalisrequiredtohaveconcerningpersonnel,equipment,datacollection,andorganizationalcapacityforeachlevel

• Prehospitalemergencymedicalservicestri-ageandtreatmentprotocolsfortraumapatients

• Requirements for collectionandreleaseoftraumaregistrydata

TheSouthDakotalegislationdoesnotallocate


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States that prohibit insurers from denying coverageColorado (2006), Connecticut (2006), District ofColumbia (2007), Illinois (2007), Indiana (2007),Iowa,Maryland,NewYork(2008),Nevada,NorthCarolina,Oregon(2007),RhodeIsland,SouthDa-kota,andWashingtonState

States that never enacted UPPL(However, courts have ruled that insurance com-panies can use alcohol/drug exclusions in states that are silent on Alcohol Exclusion Laws)

Massachusetts,Michigan,Minnesota,NewMexico,New Hampshire, Oklahoma, Utah, Vermont (re-pealedtheexplicitlawbutneverenactedprohibi-tions),andWisconsin

anyspecialfundsforthedevelopmentormainte-nanceofthesystem;rather,thefundsarecomingfromtheDepartmentofPublicHealth’sbudget.

TheKentuckylegislatureenactedH.B.371toestablish a statewide trauma system. H.B. 371createsanadvisorycommitteethatwillworkwiththestatewidetraumacaredirectortodevelopandimplementastatewidetraumacaresystem.Thissystem must include (but is not limited to) de-velopmentofguidelinesandprotocols,voluntaryhospitaltraumacenterverification(eitherbytheACSortheDepartmentofPublicHealth),andlo-calandregionaltriageandtransportprotocols.2

This legislation also creates a trauma caresystemfundthatisarestrictedaccountofstategeneral fund appropriations. Other grants andanymoneyleftinthefundattheendoftheyearwill carry over to the following year. The fundshallbeusedtopayforseveralthings,including“support foruncompensatedcare…inaverifiedtraumacenter.”3

FundingMississippipassedH.B.1405,whichisexpected

to generate approximately $32 million for thestate’straumasystem.ThemoneygeneratedbyH.B.1405comesprimarilyfromadditionalfinesonspeedingviolations.Thefinesstartat$10and

gouptoanadditional$30forspeeding.Thelegis-lationalsoincludesa$4feeoneachsetoflicenseplatetagsandanadditional$10foreachrecklessand/orcarelessdrivingoffense.

The bill also creates an escrow account andmandatesthatwheneverthetraumafundexceeds$25million, the remaining fundswill be trans-ferredtotheescrowaccountandnotbereturnedtothegeneralrevenuefund.

Injury preventionArecordnumberofsurgeonsusedtheCollege’s

Surgery State Legislative Action Center at theendofJuly,withmore than200 letters sent tolegislatorsaskingthemtosupportS.2772.Thislegislation would have provided important andreasonable regulation of all-terrain vehicles(ATVs)operatedbyminorsandwouldhavead-dressed concerns related to recreational use ofATVsbythoseintheagerangeof14to16yearsandwouldhaveprohibitedoperationbyindividu-alsyoungerthan14.

ThebillwasstalledintheWaysandMeansCom-mitteeandwasreleasedonJuly31,thelastdayofthesession,witharecommendationforpassage.Thebillwasreadatmidnight,andtwounfriendlyamendments were added. (One of the amend-mentsremovedtheagerestriction.)ThebillwasthenpulledbytheSpeakerbeforedebatecouldbeheard.Thesessionendedwithoutthebillbeingpassed.TheMassachusettsChapteriscommittedtopassingthistypeoflegislationin2009.

Repeal of the UPPL

UPPListhestatelawthatallowshealthinsur-erstodenyreimbursementforservicesprovidedtopatientsforinjuriesincurredwhenanaccidentisaresultof“theinsured’sbeingintoxicatedorundertheinfluenceofanynarcotic.”4

CaliforniahadpassedUPPLrepeallegislationforthelastseveralyears,onlytohaveitvetoedby Gov. Arnold Schwarzenegger (R). In 2007,UPPLrepealwasincludedinA.B.1461,abilltocreateapilotprojectregardingmethamphetamineintervention.In2008,thebillwasamended;thepilotprojectwasstricken,leavingonlytheUPPLrepeal.Asofpresstime,thebillhasbeenagreeduponbybothchambersandwillbepresentedtotheGovernor.


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After severalyearsof trying,NewYorkStatealso passed the UPPL repeal; unlike standardUPPLrepeallegislation,however,A.B.10000onlyappliestoautomobileinsurancepolicies,which,inNewYork,istheprimarypayorafteracrash.

Tennessee,whichdoesnotprohibittheseexclu-sions, saw a pair of bills (H.B. 2875/S.B. 3043)introducedin2008thatwouldrequirehealthcareproviderstonotifylawenforcementofficersatthehospitalifresultsoftestsperformedonthedriverofavehicleinvolvedinacollisionindicatethatthedriverhada.08percentbloodalcoholcontentorwasundertheinfluenceofdrugs.Neitherofthesebillshadanyrealmomentumandbothdieduponadjournment;thistypeoflegislationisnewtotheACS,andtheorganizationwillcontinuetomoni-torthesituation.

The UEVHPA

AnewpriorityforStateAffairsistheUEVHPA,whichwascreatedin2006andmodifiedin2007bytheUniformLawCommission;sixstateshaveal-readyadoptedthislegislation:Colorado,Indiana,Kentucky,NewMexico,Tennessee,andUtah.

TheUniformLawCommission(formerlyknownastheNationalConferenceofCommissionersonUniformStateLaws)isanonpartisanorganiza-tion devoted since 1892 to working toward thedevelopment and enactment of uniform statelaws.ThepurposeoftheUEVHPAistoallowstategovernmentstogivereciprocitytootherstates’licenseeswhoare emergency servicesproviderssothatcoveredindividualsmayprovideserviceswithout meeting the licensing requirements ofstateexperiencingadisaster.Itrecognizesana-

tional registration system used to confirm thatphysiciansandhealthcarepractitionersareap-propriatelylicensedandingoodstandingintheirrespectivestates,withtheir licensesrecognizedinaffectedstatesforthedurationofemergencydeclarations.

Theterm“healthcareprovider”isdefinedverybroadly in this legislation and includes nurses,pharmacists,morticians,andveterinarians,whichhelps to create a large and diverse coalition ofsupporters.

In2007,themodelbillwasmodifiedtoincludeli-abilityprotections.Themodellegislationincludestwooptionsfromwhichasponsormaychoose:

InAlternative‘A,’avolunteerhealthpractitio-nerisnotliable…unlesstheconductinquestionrisestothelevelofwillfulmisconduct,orwanton,grosslynegligent,reckless,orcriminalconduct….Alternative‘B’utilizesthesamebasicexclusions,butcapsthecompensationavolunteercanreceiveinconnectionwiththeemergency(notincludingreimbursement of reasonable expenses) at $500per year, and does not include the limitation onvicariousliability.5

Athird,“unofficial”optionistosimplyrefertothestate’scurrentGoodSamaritanLaws.

In2008,adozenstates introducedUEVHPA:Hawaii, Illinois, Indiana, Louisiana, Maryland,Minnesota,Mississippi,NewMexico,Oklahoma,Pennsylvania,Utah,andVermont.OnlyIndiana,NewMexico,andUtahpassedthelegislation.Thislegislationisexpectedtobeintroducedinatleastadozenstatesin2009.

Scope of practice

ThephysiciancommunityscoredabigwininTexasin2008—theTexasThirdCourtofAppealsruled that the Texas State Board of PodiatricMedicalExaminerswentoutsideitsscopewhenitadoptedarulethatexpandedthedefinitionofthefoottoincludethebonesintheankle.*Thecourtmadethisdecision,inpart,becauseintheexpandeddefinition,

...manyofthesofttissuesincludedinthisdefinitionarenotpartofthefootoreventheankle.Forex-ample,variousnervesendinginthefoot—including

*ThedefinitionofthefootasoriginallyproposedbytheTexasStateBoardofPodiatricMedicalExaminers:

Thefootisthetibiaandfibulaintheirarticulationwiththetalus,andallbonestothetoes, inclusiveofall soft tissues (muscles,nerves, vascular structures,tendons,ligamentsandanyotheranatomicalstructures)thatinsertintothetibiaandfibulaintheirarticulationwiththetalusandallbonestothetoes.

Texas Orthopaedic Association, Texas Medical Association and Andrew M. Kant, MD v. Texas State Board of Podiatric Medical Examiners, Texas Podiatric Medical Associaton, and Bruce A. Scuddy, DPM. Source: http://www.3rdcoa.courts.state.tx.us/opinions/HTMLOpinion.asp?OpinionID=16860.


29

thetibialnerve,theperonealnerve,andthesuralnerve—runalong significant portions of the legbeforereachingaterminationpointinthefoot....Similarly,severalveinsandarteries—includingthesaphenousveinandthetibialarteryandvein—alsoendinthefootafterhavingtraversedsignificantportionsoftheleg....Infact,oneofthenervesandoneoftheveinspreviouslymentionedrunalongtheentirelengthoftheleg.5

In2007,theCollegeformallyjoinedtheSteer-ing Committee of the American Medical Asso-ciation Scope of Practice Partnership (SOPP).In 2008, the SOPP awarded several grants tobothstatemedicalsocietiesandstatespecialtysocieties to fight scope battles in their states.Ineachstatewheregrantshavebeenawardedtherehavebeenphysicianvictories.

Provider taxes

The Maryland medical community cametogether on March 12, to testify in oppositiontoH.B.614.Thisbillwouldhave imposeda6percent sales tax on certain elective cosmeticproceduresperformed in thestateunless theyare determined to be medically necessary. Asintroduced,theproceduresincludedgastricby-passsurgery,breastreductionoraugmentation,teethwhitening,lasereyesurgery,rhinoplasty,facelift,liposuction,laserhairremoval,tattoo-ing,orbodypiercing.

Surgeonsatthehearingspokeaboutthefail-ureofNewJersey’scosmeticsurgerytaxtoraiseprojectedrevenuesforthatstateandemphasizedthecomplexityofdeterminingmedicalnecessityformanycosmeticprocedures.Aftermuchtesti-mony,thebillwasheldincommittee.

Certificate of Need

InApril,afteryearsofgrassrootsadvocacyonthe legislative, regulatory, and judicial fronts,Georgiasurgeonswhofoughttohavegeneralsur-gerydefinedasasinglespecialtyfinallyachievedvictory in the General Assembly. A certificateofneed(CON)reformbill,S.B.433,containedlanguage that recognizes general surgery as asinglespecialtyeligiblefortheexemptionfromtheCONprocessforambulatorysurgerycenters.

TheGeorgiaHousepassedthebill138–17,andthe Senate quickly followed suit with a 44–7voteonApril5,thelastdayofthestate’s2008legislativesession.Gov.SonnyPerdue(R)signedthebillintolawonApril9.(Formoreinforma-tionaboutthislegislation,gotohttp://www.legis.ga.gov/legis/2007_08/sum/sb433.htm.)

A final reminder

TheStateAffairsstaffintheDivisionofAd-vocacyandHealthPolicyisalwaysavailabletosurgeonsandACSchapterswhena legislativeorregulatoryissuearises.Formoreinformationonstatelegislativeissuesortodiscussaparticu-lar impending statebill or regulation, contactMelinda Baker at 312/202-5363 or [email protected].

References

1. South Dakota Legislature, Legislative ResearchCouncil. Available at: http://legis.state.sd.us/sessions/2008/Bills/SB200ENR.htm. Accessed Au-gust28,2008.

2. Kentucky Legislature, Kentucky Legislative Re-search Commission. Available at: http://www.lrc.ky.gov/record/08RS/HB371/bill.doc.AccessedAugust28,2008.

3. Uniform Accident and Sickness Policy ProvisionModelLaw(UPPL)adoptedbytheNationalAsso-ciationofInsuranceCommissionersin1947.1950Proceedings of the National Association of Insurance Commissioners,81stAnnualSession,June13,1950;Quebec,Canada.KansasCity,MO:NationalAssocia-tionofInsuranceCommissioners,1950-1952,161,950.1950NAICProc.398

4. UniformLawCommission.Availableat:http://www.uevhpa.org/DesktopDefault.aspx?tabindex=1&tabid=53. AccessedAugust28,2008.

5. FrankH.Netter, MD, Atlas of Human Anatomy482,483,485,504(2nded.1997)ascitedby:Texas Orthopaedic Association, Texas Medical Associa-tion and Andrew M Kant, MD v. Texas State Board of Podiatric Medical Examiners, Texas Podiatric Medical Associaton, and Bruce A. Scuddy, DPM.


30

Socioeconomictips

This column lists some frequently askedquestions regarding Current ProceduralTerminology (CPT)* recently posed to

theACSCodingHotlineandtheresponses.Asa benefit of membership in the College, ACSmembersandtheirstaffmayconsultthehotline10timesannuallywithoutcharge.Ifyourofficehascodingquestions,contacttheCodingHotlineat800/227-7911between8:00amand6:00pmMountainTime,holidaysexcluded.

The surgeon performed an open cholecys-tectomy with cholangiography. When the procedure was done, there was a fistula into the colon, so he repaired the colon. We are coding this surgery with code 47605, Cholecystectomy; with cholangi-ography, and code 44604, Suture of large intestine (colorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture (single or multiple perforations); without colostomy. The diagnosis for the cholecystectomy was stones. Should the surgeon give the diagnosis of fistula in gallbladder?

TheuseofthetwoCPTcodesiscorrect.TheInternationalClassificationofDiseases,NinthRevision(ICD-9),diagnosisforthegallbladderproblem is 574.00. The fistula should have adiagnosisof575.5.

The surgeon performed a laparoscopic cho-lecystectomy with removal of a common bile duct lymph node. Do I also code 38747, Abdominal lymphadenectomy, regional, in-cluding celiac, gastric, portal, peripancre-atic, with or without para-aortic and vena

ACS Coding Hotline: Cholecystectomy questionsby Linda Barney, MD, FACS; Albert Bothe, Jr., MD, FACS; and Debra Mariani, CPC, Practice Affairs Associate, Division of Advocacy and Health Policy

caval nodes (list separately in addition to code for primary procedure)?

Code for the cholecystectomy using 47562,Laparoscopy, surgical; cholecystectomy.Thereisnoextracodingforremovalofthecommonbileductlymphnode.

The procedures dictated in the operative note are cholecystectomy with choledocho-enterostomy and a gastrojejunostomy. In the note, the surgeon stated that the gas-trojejunostomy was performed 30 cm away from where the choledochoenterostomy was completed. Which codes should be used?

The codes for this surgery would be 47612,Cholecystectomy with exploration of common duct; with choledochoenterostomy, and 43820,Gastrojejunostomy; without vagotomy.

The surgeon planned a laparoscopic cho-lecystectomy but encountered problems that necessitated switching to an open procedure. The surgeon also did a partial

Around the corner

The 2009 ACS-sponsored Coding WorkshopsschedulewillbepublishedsoononourWebsiteatwww.facs.org/ahp/workshops.

November• Besuretolookforpracticemanagementtele-

conferences from Economedix. To register, go toourWebsiteathttp://www.facs.org/ahp/workshops/ teleconferences.html.

• CPTCoding&2009UpdateforDoctorsandStaffwillconveneNovember12.BuildingaBottom-LineBudgetfor2009willbeheldNovember26.

*AllspecificreferencestoCPT(CurrentProceduralTerminology)terminology and phraseology are © 2007 American MedicalAssociation.Allrightsreserved.


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shouldreporttheopenprocedurecodeonly.YoucanusethecodeV64.41,Laparoscopic surgical procedure converted to open procedure,toshowtheconversiontoopenprocedure.

The patient underwent a laparoscopic cholecystectomy, but the surgeon also did an open cholangiogram. How would I code these two procedures?

The cholecystectomy code that includes thecholangiogramis47563.Codethe laparoscopiccode,47563,Laparoscopy, surgical; cholecystec-tomy with cholangiography,withthe–22modi-fier(Increased Procedural Services)toindicatethat thecholangiographywasdoneasanopenprocedureandincludeadetaileddescriptionofthesituationintheoperativenote.

The patient had a laparoscopic cholecystec-tomy, 47563, and within the global period (90 days) of this procedure was taken back to the operating room for a Whipple proce-dure, 48150. The surgeon is also coding the +44015, Tube or needle catheter jejunostomy for enteral alimentation, intraoperative, any method (list separately in addition to primary procedure), and placed the –79 modifier on both of these codes. Is this the correct coding?

Coding the 48150, Pancreatectomy, proximal subtotal with total duodenectomy, partial gastrec-tomy, choledochoenterostomy and gastrojejunos-tomy (Whipple-type procedure); with pancreato-jejunostomy, with the –79 modifier (Unrelated procedure or service by the same physician during the postoperative period)iscorrect.Add-oncodesareexemptfrommodifierssothe–79modifierisnotnecessarywith+44015.Guidelinesforadd-oncodescanbefoundintheIntroductionoftheProfessionalEditionoftheCPT.

†Medicare Correct Coding Guide.SaltLakeCity,UT:Ingenix;2007(ISBN1-978-56337-949-9).

Dr. Barney is associate professor and associate program director for general surgery, department of surgery, Wright State University Boonshoft School of Medicine, and member, Wright State Surgeons, Miami Valley Hos-pital, Dayton, OH.

Dr. Bothe is chief quality officer, Geisinger Health System, Danville, PA.

PEG tube coding tips• If the surgeon replaces the percutaneous

endoscopic gastrostomy (PEG) tube because ofcloggingorotherfactors,code43760, Change of gastrostomy tube, ifthereisnoimageguidance.

• If the surgeon performs a replacement ofgastrostomyorcecostomy(orothercolonic)tube,percutaneous,underfluoroscopicguidanceinclud-ing contrast injections(s), imagedocumentationandreport, use 49450.

• IfthesurgeonencountersaproblemreplacingthePEGtubeandusesendoscopytodeterminetheproblemandassistinthetuberemoval,itwouldbeappropriatetocodeadiagnosticendoscopycodeand43760,Change of gastrostomy tube.

• YoucannotreportaseparatecodeforsimplePEG tube removal. Use the appropriate evalu-ation and management codes. Removing a PEGtubedoesnotqualifyasforeignbodyremoval,so43247,Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with removal of foreign bodywouldnotbeappropriate.Onlyusecode43247ifascopeisusedtoretrieveabrokenportionofaPEGtubethatremainsinthestomach.

colectomy. We are coding 44144, Colectomy, partial; with resection, with colostomy or ileostomy and creation of mucofistula, and 47600, Cholecystectomy, but the surgeon also wants to know if 49320, Laparoscopy, abdo-men, peritoneum, and omentum, diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure), for the laparoscopic portion of the proce-dure can be coded.

You generally will code procedures with thehighest relative value units first.† Use 44144,Colectomy, partial; with resection, with colostomy or ileostomy and creation of mucofistula. Therelevant ICD-9 diagnosis should also be listedon the first line of the claim form. Then code47600,Cholecystectomy.Remember,youshouldnotreportboththeopenandlaparoscopiccodesforthesameprocedure.Ifthesurgeonconvertsalaparoscopicproceduretoanopenprocedure,you


32

Collegenews

Dr.Cameron

JohnL.Cameron,MD,FACS,ageneralandthoracicsurgeonwho specializes in treatmentof alimentary diseases, wasinstalledasthe89thPresidentof the American College ofSurgeons during Convocationceremonies that preceded theofficialopeningoftheCollege’s94thannualClinicalCongressinSanFrancisco,CA,inOcto-ber.Dr.CameronistheAlfredBlalockDistinguishedServiceProfessor of Surgery at TheJohns Hopkins UniversitySchoolofMedicine,Baltimore,MD.

Dr.Cameronreceivedabach-elor of arts degree from Har-vard University, Cambridge,MA(1958),andearnedamedi-caldegreefromJohnsHopkinsUniversitySchoolofMedicine(1962). He served a surgicalinternship at Johns Hopkins(1962–1963) before he beganservice in theU.S.Armyas aresearchsurgeoninthedepart-ment of surgical metabolismatWalterReedArmyInstituteof Research (1963–1965). HereturnedtoJohnsHopkinsin1965, where he completed asurgicalresidency(1965–1970)andthenaclinicalandresearchfellowship (1970–1971)at theJohnsHopkinsHospital.

AFellowoftheAmericanCol-legeofSurgeonssince1975,Dr.Cameronhasbeenactivelyin-volvedinthegovernanceoftheCollege, including serving asTreasurer from1998to2007.Dr. Cameron has also served

asamemberoftheExecutiveCommittee(2006–2007),BoardofRegentsHonorsCommittee(2005–present), InvestmentSubcommittee of the FinanceCommittee (2002–present),andFinanceCommittee(1998to present). In addition, Dr.Cameron served as a seniormemberoftheCollege’sCom-mitteeonVideo-BasedEduca-tion(1980–1990).

Inadditiontohisservicetothe College, Dr. Cameron hasheldmanyleadershippositionsin organized surgery. He waspresidentoftheAmericanSur-gicalAssociation(2000–2001),the Halsted Society (1997–1998), the Southern SurgicalAssociation (1995–1996), theSociety of Surgical Chairs(1994–1996), the Society forSurgery of the AlimentaryTract(1991–1992),theSocietyof Clinical Surgery (1990–1991),andtheBaltimoreAcad-emy of Surgery (1985–1986).He also was a director of theAmerican Board of Surgery(1986–1992).

Trainedinbothgeneralandthoracicsurgery,Dr.Cameronhas devoted his professionallifetoseveralsignificantclini-cal and research endeavorsin alimentary tract diseases,specifically inpancreatic can-cer. A leader in alimentarytractsurgery,hehasoperatedon more patients with pan-creatic cancer anddonemoreWhipple resections than anyother surgeon in the world.

His research interests haveincluded randomized clinicaltrials and clinical outcomesinpancreassurgeryaswellasbasic laboratory research ofpancreaticdiseases,forwhichhehasreceivedgrantsupportfrom the National InstitutesofHealth.

Throughouthisdistinguishedcareer,Dr.Cameronhasexem-plifiedastrongcommitmenttothe dissemination of surgicalknowledge. He is the authorofseveral internationallyrec-ognized surgical textbooks,including Atlas of Surgery I and II, Atlas of Biliary Tract Surgery,Atlas of Clinical On-cology, and nine editions ofCurrent Surgical Therapy, andthecoauthorofEvidence Based Surgery,writtenwithTobyA.Gordon, ScD. Moreover, Dr.Cameronhasservedastheau-thororcoauthorof99chaptersinsurgical textbooksand384

Dr. Cameron installed as 89th ACS President


33

clinical and research articlespublished in the medical lit-erature. He has also contrib-utedtothesurgicalprofessionthroughhisworkasamemberof the editorial boards of thefollowing journals: Journal of the American College of

Surgeons, Surgery, Journal of Hepato-Biliary-Pancreatic Surgery, Digestive Diseases and Sciences, Asian Journal of Surgery,andThe American Surgeon. He currently is theeditor-in-chief of the Journal of Gastrointestinal Surgeryand

Advances in Surgery.Dr. Cameron currently re-

sidesinRuxton,MD,withhiswifeDorisMae.Theyhavetwodaughters,HeatherandShan-non,andtwosons,DuncanandAndrew.

Honorary Fellowships presented to five prominent surgeons

Honorary Fellowship in theAmericanCollegeofSurgeonswas awarded to the follow-ing five prominent surgeonsfromBelgium,Brazil,Ireland,UnitedKingdom,andAustraliaduringConvocationceremoniesatthisyear’sClinicalCongressinSanFrancisco,CA:

• Jacques Brotchi, MD, PhD. Dr.Brotchiispresidentof the World Federation ofNeurosurgical Societies andemeritusprofessorandhonor-ary chairman, department ofneurosurgery, Erasme Hos-pital, University of Brussels,Brussels,Belgium.

• J o a q u i m G a m a - Rodrigues, MD, FACS. Dr.Gama-Rodriguesisdirectorofgastrointestinal surgery andgastroenterology, HospitalAlemáo Oswaldo Cruz andHospitaldaBeneficênciaPor-tuguesa,SaoPaulo,Brazil.

• Gerald C. O’Sullivan, MB, BCh, FACS, FRCSGlas, FRCSI. Dr.O’Sullivan is the

immediate past-president,Royal College of Surgeons ofIreland(Dublin);lecturerandprofessorofsurgery,UniversityCollege, Cork; director, CorkCancerResearchCentre,Cork;andconsultantsurgeon,MercyUniversityHospital,Cork,Ire-land.

• Bernard F. Ribeiro, CBE, FRCSEng, FRCPEng. M r. R i b e i r o i s a p a s t -presidentoftheRoyalCollegeofSurgeonsofEngland;seniorlecturer, Middlesex Hospital,London; and director, under-graduateteachingforsurgery,University College, London,UnitedKingdom.

• Russell W. Strong, MB, BCh, FACS, FRCSEdin(Hon), F R A C S , F R C S E n g , FRACDS. Dr.Strongisemeri-tusprofessor,surgicalspecial-ties,PrincessAlexandriaHos-pital,Brisbane,Australia.

Presenting the HonoraryFellowships on behalf of theCollege were Fernando G.

Diaz, MD, FACS, Southfield,MI; Carlos A. Pellegrini, MD,FACS, Seattle, WA; Tom R.DeMeester,MD,FACS,LosAn-geles, CA; George F. Sheldon,MD, FACS, FRCSEd(Hon),FRCSEng(Hon), Chapel Hill,NC;andL.D.Britt,MD,FACS,Norfolk,VA.

This year, 1,189 surgeonsfrom around the world wereadmittedintoFellowshipdur-ing theCollege’sConvocationceremonies.

Sir Rickman Godlee, Presi-dent of the Royal College ofSurgeons of England, wasawardedthefirstHonoraryFel-lowship in the College duringtheCollege’sfirstConvocationin1913.Sincethen,413inter-nationallyprominentsurgeons,including the five chosen thisyear,havebeennamedHonor-ary Fellows of the AmericanCollegeofSurgeons.

Following are the citationspresentedduringtheConvoca-tion.


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ProfessorBrotchi

Mr.President,itismyhonorto introduce Prof. JacquesBrotchi of Brussels, Belgium,for Honorary Fellowship inthe American College of Sur-geons.

ProfessorBrotchiwasborninLiègein1942duringtheSecondWorldWar.Aftergraduatinginmedicine(MD)fromtheStateUniversity of Liège in 1967,Professor Brotchi completedhis training in neurosurgerywith Prof. J. Bonnal in thesameuniversity,wherehealsoinvested in basic research intheNeuroanatomyLaboratory(underProf.M.A.Gerebtzoff).Then,in1982,hemovedfromLiège to Brussels, where hecreatedthedepartmentofneu-rosurgeryatErasmeUniversityHospital.

Headofthedepartmentsince1982,fullprofessorandchair-manattheFreeUniversityofBrussels(ULB)since1984,hewas also director of the ULBlaboratoryofexperimentalneu-rosurgery until September 1of this year, when he becamehonorarychairmanandemeri-tus professor. He continueshis surgical act ivity as aconsultant-neurosurgeoninthedepartment.

Professor Brotchi has pub-lished more than 350 papersin international journals,withspecialemphasisonmeningio-masandsurgicalapproachesofpineal lesions and almost in-traspinal cord tumors. He hasstimulated many works in hisdepartmentwithaspecialinter-

Citation for Prof. Jacques Brotchiby Fernando G. Diaz, MD, PhD

estontheuseofpositronemis-sion tomography (PET) scancombinedwithneurosurgery—PET-guided stereotactic biop-sies; PET-guided neuronavi-gation; and, thereafter, PET-guided gamma knife treat-ment. He has also equippedhisdepartmentwithmagneticresonanceimagingand,beforeretiring, with a magnetoen-cephalography.

Deeply involved in educa-tional programs of the WorldFederation of NeurosurgicalSocieties (WFNS) since 1991,he is currently president ofthe WFNS. He has held thatposition since 2005 and willcompleteitin2009.

In1998,hisdepartmentwasdistinguished by the WorldHealth Organization (WHO)and nominated “First World-wideWHOCollaboratingCen-terforResearchandTrainingin Neurosurgery.” In 2000,he received one of the mostprestigious Belgian medicalprizes—ScientificPrize,JosephMaisin-Clinical BiomedicalSciences—withinthescientificquinquennialprizesoftheNa-tionalResearchFoundationoftheperiod1996–2000.

AmemberoftheRoyalAcad-emy of Medicine of BelgiumandoftheFrenchAcademyofSurgery,ProfessorBrotchihasbeen awarded Commandeurde l’Ordre de Leopold of Bel-gium, Chevalier de la Légiond’HonneurofFrance,Chevalierof Danneborg Order of Den-mark,andGreatCommandeur

oftheMeritOrderofSpain.In 1988, King Baudouin

of Belgium ennobled him asknightforhiscontributionstoneurosurgeryandBelgium.In2007,KingAlbertIIofBelgiumupgraded him to the rank ofbaron.

Finally, since 2004, he hasbeensenatoroftheRoyalKing-dom of Belgium and was re-electedinJune2007.Hisfieldsofinterestarehealth,medicalresearch,andbioethics.HealsohascreatedintheBelgiumSen-ateaBrainstormingGroupforPeaceintheMiddleEastthatheischairing.

JacquesBrotchiandhiswifeRachelhaveonedaughter,Na-thalie,andtwograndchildren,NinaandDylan.


35

ProfessorGama-Rodrigues

Mr. President, ladies, andgentlemen, thank you for theprivilege of introducing Prof.Joaquim Gama-Rodrigues ofSão Paulo, Brazil, for Honor-aryFellowshipintheAmericanCollegeofSurgeons.

Gama,asheisknownamonghisfriendsandcolleagues,wasborn in Cruzeiro, São Paulo,Brazil,andcompletedhismedi-cal studies at the prestigiousSchoolofMedicineoftheUni-versityofSãoPaulo.Itwasdur-inghismedicalschooltrainingthathemetRenatoLocchi—ateacher known for his inspir-ing intellectual character anddiscipline—who introducedhim to surgical anatomy andawakened in young Gama adesire to become a surgeon.Havingemulatedthedisciplineofhisteacherandusinghisowndrive, he was quickly singledout by some famous surgeonsofthetime,suchasArrigoRaiaandCorreaNeto,whoadoptedthis young student and gothim into a surgical residencyat the Hospital Das ClinicasoftheUniversityofSãoPaulo.Afterhecompletedhistraining,Gamajoinedthefacultyofhisschool,wherehequicklymovedthroughtherankstobecomeafullprofessorofsurgery.

Professor Gama-Rodriguesfocused his career on surgeryof the alimentary tract, withaparticularinterestincancerof the digestive tract, even-tually becoming director ofgastrointestinal surgery andgastroenterology at the Hos-

pital Alemão Oswaldo Cruz,SãoPaulo.His research focushas been the oncogenesis andoncogenomics and treatmentof gastric and colonic cancer.Gama is theprincipal investi-gatoroftheBrazilianClinicalCancerGenomeProject,whichwasinitiatedin2000.Theproj-ect includes seven collaborat-ing institutions and hospitalsthroughout the state of SãoPauloandtheLudwigInstitutefor Cancer Research and hasdevelopedthelargestnationalcancergenomedatabase.

Professor Gama-Rodrigues’fascinationformolecularbiolo-gyandhisunderstandingofthegeneticmechanismsinvolvedinthe carcinogenesis of tumorsofthealimentarytractledhimtosearchfornewalternativesforscreening,diagnosing,stag-ing, and treating cancer. Hisabilitytoconvincethemedicalcommunity, hospital adminis-tration,andfundraisersoftheimportanceofthiseffortledtotheformationofastate-of-the-arttumortissuebank.

Gama has a particular pas-sion for education and educa-tional systems. As a memberofmanylocal,regional,andna-tionalcommitteesandthroughtheroleheplayedinthePost-graduateCommissioninBrazil,hehasbeenabletosetinplacemodern systems of education,consolidating graduate andpostgraduate education andemphasizingtheneedfor life-longlearningandteamwork.Asaneducator,hehasrepeatedly

been honored by graduatingclasses as the Teacher of theYear and has actively partici-pated in formal mentoring ofpostgraduate students andfellowsintheareaofgastroin-testinalcancer,manyofwhomnow populate the hospitals ofBrazil. Because he embraceschange and innovation easily,he was instrumental in theadoptionof laparoscopy—and,morerecently,robotics—inhiscountryandwasrecognizedbytheBrazilianSocietyofLapa-roscopicSurgerywithitsMedalofHonor.

During his long career as asurgeon,hehasbeenparticu-larlyconcernedaboutthefateandlackofaccesstocareofthepoorandhasdevotedcountlesshours toworkingwithgroupsin safety-net hospitals to im-prove access to care for theseindividuals.Ashis interest inthe social aspects of medicine

Citation for Prof. Joaquim Gama-Rodrigues by Carlos A. Pellegrini, MD, FACS


36

andsurgerygrew,hetookad-ditional courses to become aspecialistintropicalmedicine,a discipline that deals withdiseases prevalent in Brazilandthusdirectlyaffectinghiscommunity.Gama’sinterestinpublichealthledhimtodevelopand participate extensively inpublic health campaigns likeanti-smokingand earlydetec-tionandpreventionofgastro-intestinal cancer programs.One of those programs, theColorectal Cancer Screeningprogram, first piloted in thesmallcommunityofSantaCruz

dasPalmeiras,hasbeensosuc-cessfulthatitisnowreadyforimplementation throughoutSão Paulo, one of the world’slargest metropolises with anestimatedpopulationof20mil-lion.Thisinterestinthehealthof his community led him tojointheCuratorCounciloftheOncologicalCenterFoundationin São Paulo. Today he holdsthepositionofchairmanofthecouncil,whichisastateagencyforpoliciesinprevention,earlydetection, and education forcancermanagement.

Mr. President, it is with

great honor that I presentto you Prof. Joaquim Gama-Rodrigues—a great surgeon-scientist, a respected teacher,a community leader, and aformidable human being—forHonorary Fellowship in theAmericanCollegeofSurgeons.And may I add, sir, that thisis a historic moment for ourinstitution,asGamaismarriedto Angelita Habr-Gama, whobecameanHonoraryFellowafewyearsago.Thus,thisisthefirstwife/husbandteamofHon-oraryFellowsoftheAmericanCollegeofSurgeons.

ProfessorO’Sullivan

Mr.President,itismyprivi-legeandhonortopresenttoyouthedistinguishedIrishsurgeonGeraldChristopherO’Sullivan,currently professor of surgeryat University College Cork,director-in-chief of the CorkCancer Research Center, andconsultant surgeon at MercyUniversityHospital,UniversityCollegeCork,Cork,Ireland.

Professor O’Sullivan wasborninCorkin1946wherehereceivedhisundergraduateandgraduatemedicaleducation.Hewas elected into fellowship oftheRoyalCollegeofSurgeonsofIrelandin1974andbecameitspresidentin2006.In1975,hetraveledtoEdmonton,AB,wherehereceivedhismasterofsciencedegreeinexperimentalmedicinefromtheUniversityofAlberta.In1999,hebecameaFellowoftheAmericanCollegeofSurgeons.

AttheUniversityofChicago,thelateDr.DavidSkinnerandI had the distinct pleasure ofhaving Dr. O’Sullivan workwithus for twoyearsasare-search associate, from 1979to1981.Duringthattime,Dr.O’Sullivan’s creativity as aninvestigator and his geneticcapacityasastorytellerbecameknownandappreciatedbyall.GerryimpressedonustheIrishprinciple that “no good storyshould remain untold for thelackofafewfacts.”TheChicagoexperienceaccountedforeightofhisfirst15papers—onlythebeginningofhiscurrentvolu-minousbibliography.

ItcomesasnosurprisethatProfessor O’Sullivan becamethefounderanddirectoroftheCorkCancerResearchCenter,whichcurrentlyhasa staffof32people.Thecenterhasbeenfullyactivefornineyearsand

boasts of activities that focuson the gene therapy of can-cer, creativeways to facilitatedrugdelivery to solid tumors,immunecontrolofcancer,pre-vention of colon cancer, iden-tificationand therapyofbonemarrow micrometastasis, and

Citation for Prof. Gerald C. O’Sullivanby Tom R. DeMeester, MD, FACS


37

thebiologicalbehaviorofuppergastrointestinalcancers.

ProfessorO’Sullivan’s clini-calinterests,asexpected,areinsurgicaloncologywithafocusonuppergastrointestinalsur-geryforbenignandmalignantdisease.Throughhisresearch,lectures,writing,andpractice,patientsandsurgeonsthrough-out the world have benefitedfromhisknowledge,expertise,andcompassion.Forhiswork,hehasbeenwidelyrecognizednationallyandinternationallyasanoutstandingcommunica-torandhasdeliveredmorethan11 named lectures. ProfessorO’Sullivan is president-electof the European Surgical As-sociation, and he has servedwithdistinctionaspresidentoftheRoyalCollegeofSurgeonsinIrelandandtheIrishSocietyofGastroenterology.

WhilepresidentoftheRoyalCollege of Surgeons in Ire-

land, Professor O’Sullivanestablished a surgical train-ing program in 10 countriesin East and Central Africathrough collaboration withthe College of Surgeons ofEast, Central, and SouthernAfrica.Thedevelopmentofanintercollegiate structure hasprovidedhigh-qualitysurgicaltraining in those countries.He also developed a strategyto enable surgical researchby all surgeons in Ireland ir-respective of their hospitaltypeorsurgicalspecialty.Thisstrategyinvolvedcreationofanetworktofacilitatecollabora-tion,createanopportunityforintercalateddoctoralprogramsfor suitable candidates, andorganizeastructuretoprovide,manage,andcoordinategenericsupport.

During his outstanding ca-reer,ProfessorO’Sullivanhasbeenfortunatetohavethelov-

ingsupportofhiswife,Breda,for36years.Theyhave threechildren—Orla, Gearoid, andEoghan.Itisdifficulttofathomthat with all he has done hewouldhavesparetime,buthedoes find and cherish time toread extensively and practicearmchairphilosophywithever-presentguests.

Mr. President, Prof. Ger-ald O’Sullivan is known andloved by many surgeons andphysicians. His investigativestudies,creativethinking,andprovocativelectureshavehadaprofoundimpactonIrish,Euro-pean,andAmericansurgery.Hehasachievedhisobjectiveswithindefatigable energy, innova-tivethinking,andcollaborationwith colleagues. He is a mostworthy recipient of HonoraryFellowship in the AmericanCollegeofSurgeons.

Mr.Ribeiro

Mr.President,itismyhonortopresentMr.BernardRibeiroof Hampshire, England, forHonorary Fellowship in theAmericanCollegeofSurgeons.

Mr. Ribeiro is an accom-plished international surgeonand is the immediate past-presidentoftheRoyalCollegeof Surgeons of England. Hefollows many previous RoyalCollege presidents in becom-inganHonoraryFellowofthisCollege, including our firstHonoraryFellowatthefound-ingoftheAmericanCollegeof

Surgeonsin1913,SirRickmanGodlee.

Mr. Ribeiro is of British/Ghanaiannationality.Hisedu-cation was at the Dean CloseSchool in Cheltenham (1957–1962) and Middlesex HospitalMedicalSchool(1962–1967).

After concluding training,he was appointed consultantsurgeon to Basildon Hospital,Essex,whereheintroducedlap-aroscopicsurgerytotheTrustand established an advancedlaparoscopicunitthathasper-formedmorethan1,000chole-

Citation for Mr. Bernard Ribeiro by George F. Sheldon, MD, FACS, FRCSEd(Hon), FRCSEng(Hon)


38

cystectomies. His involvementinundergraduateandgraduateeducationwasinstrumentalinforging links with UniversityCollegeLondon,whichcontrib-uted to the Trust achievinguniversitystatusin2002.

Mr.Ribeiro’sleadershipskillswere recognized early in hiscareer. He became secretaryand then president of the As-sociationofSurgeonsofGreatBritainandIreland(ASGBI)in1991 through 2000. He repre-sentedtheASGBIontheSenateof Surgery, an organization ofthe four surgical colleges andnine specialist associations inGreat Britain and Ireland. Hewas elected to the Council ofthe Royal College of Surgeonsof England in 1998, and hereceiveda fellowship fromtheRoyal College of Surgeons ofEdinburgh ad hominem in2000.In2004,hewasappointedCommanderoftheOrderoftheBritish Empire for services tomedicine.

ThecrowningorganizationalachievementofMr.Ribeiro’sca-reerwaselectioninJuly2005toathree-yeartermas presidentof The Royal College of Sur-geons of England. Continuingthe work of his predecessors,hepresidedovertheexpansionof the Royal College’s leadinghistoricalroleinsurgicaleduca-tion.ThefacilitiesoftheRoyalCollegeofSurgeonshavebeenexpanded, the Hunterian Mu-seumhasbeenremodeled, theeducation and training facili-tieshavebeenupgraded,andapolicyunithasbeenestablishedattheheadquartersatLincoln’sInnFields.Hispresidencysawthecommencementofthesuc-cessfulEagleProject,forwhich

thefirstcompletedstageistheWolfsonSurgicalSkillsLabora-torythathasbenchtopclinicalskills areas and minimally in-vasivesurgerysimulationtools.HealsoinitiatedanindependentexternalreviewofthestructureandactivitiesoftheRavenDe-partmentofEducation.

Mr. Ribeiro’s presidencycame as the National HealthService(NHS)wasundergoingextensivereorganization,whichincludedchangeswithnegativeimplicationsforphysiciansandsurgeons in training. The seachangeintheformatofBritisheducation occurred within thecontext of the NHS programModernising Medical Careers(MMC). Part of the reorgani-zation included the MedicalTraining Application Serviceas a cornerstone of the MMCinitiative. Unfortunately, theimplementationoftheprogramproducedmanyproblems,whichincludedinsufficientnumbersofadvancedtrainingpositions.Mr.RibeiroledtheUnitedKingdomin working constructively butfirmly to ensure that patientcare would be unaffected andthat the flawed recruitmentprocess would not mar thecareersofagenerationofcom-mittedtrainees.Hesuccessfullysecured a significant tempo-raryexpansionofST3surgicaltrainingposts.Whilesodoing,he shared his experience withthe international community.Theexperienceofdealingwitha shortage of funded trainingpositions insurgery isalsooc-curringintheU.S.

Mr.Ribeirohasledtheinter-nationalcommunityinaddress-ingtheproblemsraisedbytheEuropeanWorkingTimeDirec-

tive(EWTD),theequivalentofthe Accreditation Council onGraduateEducation’s80hourworkweek requirement. In2008, he joined the leadershipoftheAmericanCollegeofSur-geons in presenting testimonyonworkhourstothe Instituteof Medicine of the NationalAcademyofSciences’Optimiz-ing Graduate Medical Trainee(Resident) Hours and WorkSchedules to Improve PatientSafetypanel.Hedescribedtheimpact on surgical educationin England and elsewhere inthe EuropeanUnion undertheEWTD. The American Collegeof Surgeons has been a ben-eficiary of his participation inpostgraduate programs at theClinicalCongress.

Bernie, as he is known, is adevotedfamilyman.Heandhiswife,Liz,haveonesonandthreedaughters, two of whom aretwins.HissonRichardandhiswifeJoannehavegivenBernieand Liz their first grandchild.Bernie and Liz have movedrecently from Essex to Hamp-shire, where Liz is overseeingextensivebuildingandrenova-tion. They have a stretch oftheRiverItchen,whereBernieenjoys his passion for fishing.AnothermemberofthefamilyisablackdognamedMegthatBernieclaimsisagoodretriever,butinrealityisapet.

AspresidentofTheRoyalCol-legeofSurgeonsofEngland,Mr.BernieRibeirowillbe remem-beredasthetrainees’advocate,muchashisclosefriend,ClaudeOrgan,MD,FACS(deceased),isremembered as the residents’presidentoftheAmericanCol-legeofSurgeons.


39

ProfessorStrong

Mr.President,itismyhonortopresenttoyouProf.RussellWalker Strong of Brisbane,Australia, for Honorary Fel-lowship in the American Col-legeofSurgeons.

Professor Strong was borninLismore,NewSouthWales.He is currently professor ofsurgery at the University ofQueensland in Brisbane anddirectorofsurgeryatthePrin-cessAlexandraHospital.Pro-fessorStrongcompletedhisun-dergraduatemedicaleducationat the University of London.He remained in England forhisgraduatemedicaltraining,wherehewastheseniorhousesurgeon at the BirminghamAccident Hospital, the surgi-cal registrar at the CharingCrossHospitalinLondon,andthe senior surgeon registrarat the Whittington Hospital,London.

Professor Strong movedsouth to Brisbane to launchhis academic career. StartingasasurgicalsupervisoratthePrincess Alexandra Hospital,his rapid ascent in academicsurgerywasremarkable.Pro-fessorStrongwasselectedtobetheJamesIVTravellingFellow,which afforded him the op-portunity to have intellectualexchangeandsharehistechni-calexpertisewithmanyofhisinternationalcolleagues.

The recipient of an almostendlesslistofacademicawardsandhonoraryfellowships,Pro-fessorStrongisacknowledgedby experts in the field as one

of the top liver surgeons inthe world. He has more than260 scientific publicationsto his credit, including 14book chapters. His landmarkcontributions to the medicalliteraturehavepavedthewayforthedefinitivemanagementofsomeofourmostchallenginghepatic injuries and diseases.He developed and pioneeredthe “Brisbane technique” ofreduced-size liver transplantforchildren.ProfessorStrongperformedthefirstsuccessfullivingrelatedlivertransplantin the world in 1989, whena portion of a mother’s liverwastransplantedintoherson;botharealiveandwell19yearslater. He now has an impres-sive personal series, which isconsideredbymanytobeun-paralleledwithrespecttobothnumbersandoutcomes.

ItisacertaintythatProfes-sor Strong’s legacy will con-tinue for generations, for hehasbeenveryactiveintrainingyoungsurgeons,particularlyinSoutheastAsia.Hehastrainedmore than 80 surgeons fromoverseas in hepatobiliary andlivertransplantsurgery.ManyofhisfellowshavereturnedtoIndonesia, Japan, Malaysia,and several other countriesto become leaders in hepaticsurgeryandlivertransplanta-tion.

Inadditiontohisinnumera-bleacademicaccolades,Profes-sorStrongisahighlydecoratedcivilian.HewashonoredastheQueenslander of the Year in

1986andwastherecipientofthe Companion of the Distin-guished Order of St. Michaeland St. George presented byHerMajesty,QueenElizabeth,atBuckinghamPalace.Healsoreceived Australia’s highestcivilianhonor,theCompanionoftheOrderofAustralia.

Professor Strong, the con-summate clinician/surgeon,educator, investigator, andhumanitarian,embodiesallthelaudabletenetsofanhonoraryfellowship.

Mr. President, it is my dis-tinctprivilege topresent thisworld-renownedsurgeon,Prof.Russell Strong, for HonoraryFellowship in the AmericanCollegeofSurgeons.

Citation for Prof. Russell W. Strongby L. D. Britt, MD, FACS


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A M E R I C A N C O L L E G E O F S U R G E O N S • D I V I S I O N O F E D U C A T I O N

EXAMINE THE ETHICAL UNDERPINNINGS OF THE ISSUES

YOU FACE EVERY DAY

TOPICSFramework for considering ethical issues in clinical surgeryCompetition of interestsTruth telling and the surgeon-patient relationshipConfi dentialityProfessional obligations of surgeonsEnd-of-life issuesSubstitute decision making

•

••

••••

FEATURES OF EACH CHAPTERRealistic surgery-based casesLearning objectivesQuestions for discussionAnalyses of cases and questionsBioethics bottom lineSuggested readingsGlossary and additional resources

•••••••

A case-based educational resource for surgeons at all stages of their careers,

has all the components needed to help surgeons and residentsexamine the ethical underpinnings of clinical practice

and address the ethical issues they face every day caring for their patients

Ethical Issues in Clinical Surgerywas developed by theCommittee on Ethics of the American College of Surgeons.

� ere are two versions of the book: one for course instructors and practicing surgeons that has CME credit available, and one for use with residents.

Pricing and ordering information can be found at http://www.facs.org/education/ethicalissuesinclinicalsurgery.htmlor by calling 312/202-5335.

ETHICAL ISSUES IN CLINICAL SURGERY

Ethical Issues in Clinical SurgeryEdited by Mary H. McGrath, MD, MPH, FACS

Ethical Issues ad (09-07) - Bull1 1 8/27/2008 9:59:32 AM

James C. Thompson, MD,FACS, oneof the leading sur-gicalscientists,educators,andstatesmen of the past half-century, died at age 79 in hishome in Galveston, TX, onMay9,ofprostatecancer.From1970to1995,hewaschairmanof the department of surgeryat the University of TexasMedical Branch (UTMB) inGalveston,wherehealsoservedastheAshbelSmithProfessorofSurgeryandasprofessorinthe department of physiologyand biophysics. He is widelycredited with building one ofthe leading surgical scientificprogramsintheU.S.andwithbringing about a sea changethroughoutUTMBineducationandresearch.

J im Thompson was notborn with a silver spoon inhismouth.Hegrewup inthelittlecowtownofHebbronvillein Jim Hogg County in southTexas, population 3,000. Hisfather owned the town hard-ware store and died while ona hunting trip on horseback,whenJimwas14yearsofage.Atbest,theeconomicconditionofthefamilywasmodest.Jimattendedgradeschoolandhighschoolinthesingle,littleHeb-bronvillepublicschool.In1944,whenhehadjustturnedage16,heenteredtheAgriculturalandMechanical College of Texas,

now Texas A&M University,graduating with a bachelorof science degree in just twoyears. In 1946, when he hadjustturned18years,heenteredmedical school at UTMB. Hisfamilywasdirt-poorandeventhough the tuition was small,hedroppedoutafterhisfresh-man year to earn sufficientfunds to continue his medicaleducation. He worked as apaidlaboratoryassistanttoDr.RaymondBlount,professorofanatomy,ultimatelyearningamaster’sdegreeinanatomyandendocrinologysomeyearslater.HereturnedtomedicalschoolatUTMBin1948andwentontoservearotatinginternshipat

UTMBfrom1951to1952.Toward the end of his in-

ternship, he applied all overthecountryforaresidencyinsurgeryandwasturneddownbyeveryinstitutionexceptone,andthatwasafluke.Theoneprogram that accepted himtentativelywasattheUniver-sity of Pennsylvania, headedby I. S. Ravdin, MD, FACS,whosenthimatelegramthatread, “We are of course full,but any descendant of the fa-mous James E. Thompson ofGalveston iswelcome intomyprogram.Wewillputyouintothe Harrison Department ofSurgical Research for a year,andthenyoucancomeintotheclinic.” Jim Thompson didn’thaveaclueastowhoJamesE.Thompsonwas.Infact,JamesE.Thompsonwasthefoundermany years earlier of the de-partmentofsurgeryatUTMB.Itwasaclearcaseofmistakenidentity,whichJimThompsonlet pass, given his desperatecircumstances.

Afterayear in theresearchlab, Jim Thompson enteredthe clinical surgery residencyatPennin1953andcompletedresidencyin1959.HistrainingwasinterruptedduringtheKo-reanWarbythe“doctorsdraft,”which resulted in a two-yearstintintheU.S.ArmyMedicalCorps in Germany, where he

Inmemoriam

James C. Thompson, MD, FACS, 1928–2008by Marshall J. Orloff, MD, FACS

Dr.Thompson


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achievedamodicumoffameinArmycircles.TheArmyclassi-fiedhimasaphysician,generalduty, not a surgeon, and as-signedhimtoasmallbattalionclinicinMunich,wherehetookdailysickcall.Inthatcapacity,hesawsoldieraftersoldierwiththeunfortunatesociallytrans-mitted disease of gonorrhea.The soldiers were very upsetby the knowledge that theyhadgonorrhea,mainlybecausethey feared demotion or evenexpulsion from the Army. So,kindly, Lt. James Thompson,MD, recorded in the medicalrecordadiagnosisoflaryngitisforeachofthesesoldierswithgonorrhea.Armymedicalhead-quarters in Washington, DC,was alarmed by the unusualoutbreak of laryngitis in Mu-nichandsentateamofseniorinfectious disease specialistsand epidemiologists there toinvestigate. Needless to say,interrogation of LieutenantThompsonuncoveredthetruthof the matter, but the inspec-torswere so impressedbyhiskindness and ingenuity thatthey covered up the reportedepidemicoflaryngitis.

I first met Jim Thompsonlate at night in October 1952in the research laboratoriesof the Harrison DepartmentofSurgicalResearchatPenn.We liked each other from thestart and we saw each otherregularly from then on, andthroughoutthenext56years.Irecognizedhisenormoustal-ent and engaging personality,butIdonotbelievetheseniorsurgical faculty at Penn fullyappreciatedhispotential,afactthatonlyservedtoincreasehisdetermination to succeed as

anacademicsurgicalscientist.Whenhecompletedthesurgi-cal residencyatPenn,hewasshuntedofftotheoldPennsyl-vania Hospital, a Penn affili-ate, to fend forhimself.WhatheaccomplishedonhisownatthePennsylvaniaHospitalfrom1959 to 1963 was remarkableandatributetohisdetermina-tion, tenacity, and ability. Heestablishedafirst-ratesurgicalresearchlaboratoryonhisown;obtainedresearchgrantsfrommajor agencies, including theNational InstitutesofHealth,on his own; published paperafterpaperongastrointestinalphysiology and disease on hisown; and attracted the atten-tionofleadinggastrointestinal(GI) scientists from the U.S.and abroad, such as LesterDragstedt, Roderick Gregory,andMortonGrossman.

In 1963, knowing that histalentwasnotfullyappreciatedandrecognizedatPenn, IwasabletorecruithimtoUniversityofCalifornia–LosAngelesHar-borGeneralHospital,whereIwas chief of surgery. In 1967,he succeeded me as professorandchiefofsurgery.AtHarborGeneralHospital,hecontinuedhisremarkablyproductiveca-reer as an academic surgicalscientist, so much so that in1970, he was recruited by hisalmamater,UTMB,toreturnas professor and chair of sur-geryforthenext25years.

Scientific contributionsTheresearchlaboratorythat

JimThompsonestablishedwasinvolvedcontinuouslyinthein-vestigationofbasicandappliedprinciplesofGIphysiologyandendocrinology. The numer-

ous original and far-reachingstudies undertaken by theThompson laboratory focusedparticularly on identificationand function of GI hormonesinhealthanddisease.TheworkwasmadepossiblebyresearchgrantsthatJimThompsonob-tainedcontinuouslyfor41yearsfrom the NIH under highlycompetitivecircumstances.ThelaboratoryandclinicalresearchaccomplishedbytheThompsongroupresultedin616publica-tionsinpeer-reviewedjournals,120 book chapters, and 588scientific abstracts in the 54yearsfrom1953to2007,are-markablerecordofproductivitythat few academic surgeonshaveequaled.

Service to surgery and society

Jim Thompson’s record ofservicetosurgeryandtosocietyisunsurpassed.Hewaselectedtothepresidencyofsixmajornationalsurgicalorganizations,includingtheAmericanCollegeofSurgeons,theAmericanSur-gical Association, the South-ern Surgical Association, theSocietyforSurgeryoftheAli-mentary Tract, the Society ofSurgicalChairs,andtheJamesIVAssociationofSurgeons.HealsoservedaspresidentoftheTexasSurgicalSocietyandtheSouth Texas Chapter of theAmericanCollegeofSurgeons.He was heavily involved inservicetotheAmericanCollegeofSurgeons,havingservedasChairman of the CommitteefortheForumonFundamentalSurgical Problems, a memberof theBoardofGovernors forsix years, a member of theProgram Committee for 10


43

years,ChairmanoftheSurgi-cal Research and Educationcommittee, and a member ofthe Scholarship Committee.He also served as chairmanoftheMeritReviewBoardforSurgery of the U.S. VeteransAdministration, adirector forsixyearsoftheAmericanBoardofSurgery,anassociateeditoroftheYearbook of Surgery,andamemberoftheeditorialboardoftheJournal of the American College of Surgeons.

Contributions to educationArguably, Jim Thompson’s

mostlastingcontributionswerein education. He trained 131researchfellowsfromtheU.S.and18foreigncountriesinthefundamentals of scientific re-search.Alongwithhisfacultycolleagues, he trained morethan 200 residents in clinicalsurgery.Twelveofhisstudentsadvanced to the position ofchairmanofthedepartmentofsurgery and/or full professorat major universities. Duringthecourseofhiscareer,hewasinvited265timestoserveasavisiting professor at universi-ties in the U.S., Europe, theFarEast, India,Africa,SouthAmerica,andCentralAmerica.Hisinfluenceontheeducationofsurgeonswasworldwide.

HonorsAmonghismanyhonors,the

twothatheprizedmosthighlywerehiselectionstotheInsti-tuteofMedicineoftheNationalAcademyofSciencesandtotheAmerican Philosophical Soci-ety.Inaddition,hewaselectedtomembership in56nationalprofessionalandscientificorga-nizations.Tenforeignsurgical

societiesselectedhimashonor-arymember,andtheUniversityofBeijingmadehiman“honor-aryprofessorforlife.”In1993,the44thvolumeoftheSurgical Forum was dedicated to Jim,andin1996theAmericanCol-lege of Surgeons selected himfor the Distinguished ServiceAward. He received a simi-lar award from the NationalMedical Association and aLifetime Achievement AwardfromtheSocietyofUniversitySurgeons.

Qualities of character and personality

The most important andlastingattributesofamanarethe qualities of his characterand personality. In regard toJim Thompson, those quali-tieswerehisessence.Thefirstquality was his incredible te-nacityanddetermination.Hisbackground is a story of “weshallovercome”:Heovercamea background of near pov-ertyinasmallTexastown;heovercame poverty that forcedhim to interrupt his medicaleducation;heovercamelackofrecognitioninhisresidencyatPenn; and he overcame beingshuntedtoabackstreamhospi-talatthestartofhisacademiccareer.Withdeterminationandtenacityandnoathleticexperi-ence,attheageof60,hetookupsnowskiingandgaveitupsomeyearslateronlyafterhesustainedahipfractureontheslopes.Importantly,asaresultofdetermination,tenacity,andability,hechangedUTMBandbuiltoneoftheleadingsurgicalscientificprogramsintheU.S.,where nothing like it existedwhenhearrivedinGalveston.

The second Thompson at-tributethatdeservescommentwas his unflagging support ofthe young people in his pro-gram and of his coworkers.He learned early in life thatthe main responsibility of anacademicleaderistohelpandnurture and mentor thoseunder him, and that the ac-complishments of the troopsultimately reflect glory, notonlyonthemselvesbutalsoontheleader.Hestronglybelievedthattheirsuccesswashissuc-cess.Duringmanyofourcon-versationsovertheyears,oftenwith obvious pleasure, he ex-tolledtheabilitiesandvirtuesofhispeople.Inpreparingthismemorial tribute, I carefullyexaminedhiscurriculumvitae.Asareflectionofhisnurturing—and it is only a sample—ofhis616peer-reviewedpublica-tions,CourtneyTownsend,MD,FACS,wasaco-authorin245;MarkEvers,MD,FACS,in51;DanBeauchamp,MD,FACS,in43; Gerald Fried, MD, FACS,in 15; David Herndon, MD,FACS,in14;BillNealon,MD,FACS, in12;andHugoVillar,MD,FACS,in9.JimThompsonwasandwillremainamodelofeffectiveleadership.

The third Thompson attri-bute,andonethatfewsurgeonspossess, is intheareaofnon-medicalculture.JimThompsonwastrulyaculturedman,withserious interests and knowl-edge in literature, art, andmusic.Manyofhiscolleaguesconsideredhimtobethemostcultured person in the city ofGalveston,amostunusualac-coladeforasurgeon.OnehadonlytovisitthelargeThomp-sonhomeonBayouShoreDrive


44

• Viewsurgicalnews• Interactwithsurgicalcommunities• UpdateCMEcredits• Entercaseloginformation• Trackresidenthours andmore—allat:

e-facs.org

toexperiencestrikingconfirma-tionoftheseculturalinterests.Thewalls ineveryroomwerelinedbybookcasesfilledwithawidearrayofbooks,bothnon-fictionandfiction.JimwasthemostavidreaderwhomIhaveknown.Thewallsandceilingsof every room, including thekitchen, were papered withoriginalartworkfromalloverthe world. And the collectionofclassicalandmodernmusicCDsandtapeswasstaggering.Youmightask,“Whatdidtheseinterestshavetodowithhisjobasachairofthedepartmentofsurgery?” They enhanced hisunderstanding of his patientsand of the human condition.Moreover,hisculturalinterestsmade him a most interestingcolleague and friend—far outoftheordinary.

The fourth attribute thatdeservescommentisaqualitythatmanyfindwantingwhenthey face difficult choices (asthey say, when the chips are

down)—that is, the quality ofloyalty. Jim Thompson wasintensely loyal to his friends,tohiscolleagues,tohisdepart-ment,tohisinstitutionUTMB,and to Texas. I sometimesasked myself, if I were in thetrencheswiththeVietCongorNorth Koreans coming at mewithgunsblazing,whowouldI want in the trenches withme?Theanswerwas,withoutdoubt,JimThompson.

The final attribute that de-servescommentishiswarmthofpersonality.Wordsthatchar-acterizehispersonalityincludecolorful,irreverent,sometimesoutrageous, funny, bombastic,eloquent,occasionallyinoffen-sively vulgar, charming, andengaging. He was never dull.Above all, he was fun to bewithinsocialsituationsandanunforgettable friend. I doubtthattherewilleverbeanotherprofessorofsurgerylikehim.

Jim Thompson will be re-membered forever by his stu-

dents, residents, research fel-lows, and coworkers—youngandmaturealike—asaninspi-rationalteacherandrolemodelofwhatauniversityprofessorshould be. He will be remem-beredbyhiscolleaguesandthesurgicalprofessionasaleaderwho influenced the course ofa great university. He will berememberedbyhismany,manyfriendsasawarm,thoughtful,generous, loyal, and engagingmanwhoenrichedthelivesofallwhohadthegoodfortuneofcoming to know him. And, ofcourse,hewillbesorelymissedbyhissixchildren,fivegrand-children, longtime companionBebe Jensen, and the entireOrlofffamilywhoknewhimasUncleJim.

Dr. Orloff is Distinguished Pro-fessor of Surgery, Emeritus, in the department of surgery at University of California–San Diego.


45

The Executive Committee on Video-Based Education and Ciné-Med have developed the interactive Multimedia Atlas of Surgery.Each volume presents a comprehensive list of surgical procedures, featuring:

• Narrated surgical video• Didactic presentations• Medical illustrations• Expert commentary• Foreword by Ajit K. Sachdeva, MD, FACS, FRCSC, Director, Division of Education, American College of Surgeons

To order,call 800/633-0004

or visitwww.cine-med.com

Editors:Tonia M. Young-Fadok, MD, MS, FACS, FASCRSHoracio J. Asbun, MD, FACS

Pricing:DVD-ROM with monograph, online access, and podcast downloads: $2701-year online subscription: $180Individual chapters: $35 each (CD-ROM) $20 each (1-year online subscription)

Presented byPresented by

Formats:• DVD-ROM• Online• Podcast• Monograph

ACS Multimedia Atlas of Surgery

Volume I:Colorectal Surgery

American College of Surgeons • Division of Education:“Improving the Quality of Surgical Care through Education”

THE AMERICAN COLLEGE OF SURGEONS • D IV IS ION OF EDUCATION

Atlas of Surgery ad (Feb 08) - B1 1 3/11/2008 4:14:00 PM

Richard A. Santucci, MD,FACS, professor of urologyin the College of OsteopathicMedicine at Michigan StateUniversity, East Lansing, hasbeen selected as the 2009ACSTravelingFellowtoGer-many.

Dr.Santuccihasresearchedand written extensively ongenitourinary trauma andreconstruction, as well as onmore customary urologicaltopics.

As the Germany TravelingFellow, Dr. Santucci will par-ticipate in the annual meet-ing of the German SurgicalSociety in Munich, Germany,

Germany Traveling Fellow selected for 2009

April28–May1,2009.Hewillattend and participate in theACS’GermanyChaptermeet-ingduringthatevent.Dr.San-tucciwillalsotraveltoseveralsurgical centers in Germany,withassistance frommentorsprovidedbytheGermanSurgi-cal Society and the GermanyChapter.

Theapplicationdeadlineforthe2010TravelingFellowshipto Germany is April 1, 2009.Therequirementswillbepub-lishedinafutureeditionoftheBulletinandhavebeenpostedto the College’s Web site athttp://www.facs.org/member services/acsgermany.html.

Dr.Santucci

Dr.Eastman


47

TheBoardofScientificCoun-selors, National Center forInjury Prevention and Con-trol, has appointed A. BrentEastman, MD, FACS, to serveon the 13-member board thatadvises the Secretary of theU.S. Department ofHealthand Human Services and theDirectoroftheCentersforDis-easeControlandPrevention.

Theboardwillexaminestrate-giesandgoalsforprogramsandresearch within the nationalcenter, conduct peer review ofscientificprograms,andmoni-tor the overall strategic direc-tion and focus of the national

Dr. Eastman appointed to national injury prevention advisory board

center.Theboardalsoperformssecond-levelpeerreviewofappli-cationsforgrants-in-aidforre-searchandresearchtrainingac-tivities,cooperativeagreements,andresearchcontractproposalsrelatedtothebroadareaswithinthenationalcenter.

AFellowoftheCollegesince1976,Dr.EastmanhasservedontheBoardofRegentssince2001andhasbeenanactivepartici-pantinitstraumaprogramsandactivities. He is currently thechiefmedical officeratScrippsHealth and N. Paul WhittierChairofTrauma,ScrippsMemo-rialHospital,LaJolla,CA.

2009 Coding Workshops

American College of Surgeons2009 Coding Workshop Seriesfor Surgeons and Their Staff

FT. LAUDERDALE, FLFebruary 26

2009 Introduction to CPT, ICD-9-CM, and evaluation and Management Coding

February 27

2009 Surgical and Office-based Coding and reimbursement (advanced)

ST. LOUIS, MO

May 14


May 15


CHICAGO, IL

JuLy 9


JuLy 10


LOS ANGELES, CA

auGuST 27


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For more information

and to register, go to

http://www.facs.org/ahp/workshops/index.htmlor contact

Debra Mariani,

Practice affairs associate,

tel. 202/672-1506,

e-mail [email protected]

2009 Coding Workshop ad-Bulletin1 1 9/17/2008 4:24:45 PM

The objectives of my visitto Japan were to attend the108th Congress of the JapanSurgicalSociety(JSS)inNa-gasaki, stimulate scientificexchange, and develop newfriendshipsandresearchcol-laborations.Iwasreadilyabletoaccomplishtheseobjectivesduring the Japan TravelingFel lowship, with my wifeNatalieeagerlyaccompanyingme,andIamalreadyplanningafuturevisit.

TokyoI arrived in Tokyo before

the JSS meeting to visit theNipponMedicalSchoolwhereI was hosted by Prof. KazuoShimizu,MD,PhD,chairmanof the department of sur-gery (see photo, this page).Thefirstdayofmyvisitwasspent in the operating room(OR)withProfessorShimizu,whereIhadtheopportunitytowatchhimcarryoutathyroid-ectomyandneckdissectionforcancer. I was very impressedwiththeintraoperativeteach-ing and mentorship he gaveto junior surgical staff, sur-gical residents, and medicalstudents. It was in the ORwith Professor Shimizu thatIhadmyfirstopportunitytoobservealateralneckdissec-tion in Japan. We also spokeatlengthabouttheextentoflymphadenectomyforthyroidcancer.

Overlunchwithjuniorstaff,residents, and students, wehad in-depth discussions onmany interestingtopics. Ies-peciallyenjoyedlearningaboutthe use of adjuvant therapyfor thyroid cancer in Japan.We also had the opportunityto discuss the video-assistednecksurgeryapproachtothy-roidandparathyroidsurgery,a technique that ProfessorShimizuhaspioneered.

Ihadtheopportunitytotourthe Nippon Medical Schoolandvisittheoutpatientclinic,

inpatientwards,radiology,andthelaboratory.KiyomiYamadaHames, MD, PhD, a clinicalfellow in endocrine surgerywho had recently returnedfromcompletingherresearchtraining in Boston, MA, wasan excellent tour guide andtaught me much about themedical system in Japan. Itwasthrillingtovisitthebeau-tiful Shinto shrine locatedjustacrossthestreetfromthemedicalschool.

I also had the opportunitytomeetandspeakwithmany

Report of the 2008 American College of Surgeons Japan Traveling Fellowby Sam M. Wiseman, MD, FACS, FRCSC

Dr.WisemanwithhishostinTokyo,ProfessorShimizu.


49

endocrinesurgeonsandtrain-ees at the school, includingassociate professors HarukiAkasu,MD,PhD,andTakehitoIgarashi, MD, PhD; assistantprofessor Ritsuko Okamura,MD, PhD; and clinical fellowTomoo Jikuzono, MD. Ev-eryone was very friendly andwelcoming and I was able toanswer many questions forthem regarding thyroid andparathyroid surgical surgeryinCanada.Ialsohadtheplea-sureofmeetingandspeakingwithKojiYamashita,MD,PhD,about his experience using atransaxillary retromammary,video-assisted breast surgery(VABS) approach for breastconservationsurgery.

The weekend was spentsightseeing with Natalie inTokyo, an incredibly largeand diverse city with a veryefficient and user-friendlymass transit system. Sight-seeing highlights from theweekend included attendingsumowrestlingmatchesintheKokugikanarena,visitingtheAsakusa Shrine and TsukijiFishMarket,andexploringtheShinjuku,Ginza,andShibuyaareas. The Akihabara “Elec-tric Town” was overwhelm-ing,withmoreelectronicsondisplay and for sale than Icouldhaveeverimaginedwaspossible.

The highlight of the week-end was an authentic Japa-nesemealhostedbyProfessorShimizu in a beautiful venuelocated in a lush park in To-kyo.Manyinterestingdiscus-sionsoverdinnerincludedthecurrent surgical approach toparathyroid disease in Japanandminimallyinvasivesurgi-

cal management of adrenaltumors.

Thefollowingmorning,Iwaswarmly received at the Nip-pon Medical School surgicalroundsandreport.Atrounds,Iheardaveryinterestingpre-sentationonVABSforinsitubreast cancer anddeliveredapresentationonmyresearchofmolecular diagnostic markersforthyroidcancer.Thereweremany interesting commentsandquestionsandthediscus-sion that followedwasstimu-lating.Beforemydeparture,IspokewithProfessorShimizuand Dr. Hames about severalfuture collaborative researchprojects.Afterrounds,wewereofftoKobeontheshinkansen(bullettrain)thatwefoundtobea fastandpleasantwaytotravelthecountry.

KobeThe next stop was Kobe,

whereIvisitedtheKumaHos-pital andwashostedbyProf.Akira Miyauchi, MD, PhD,directorofthethyroiddisease-focused medical center (seephoto, this page). I attendedthehospital’smorningconfer-encewhereIverymuchenjoyedpresentationsonseveraltopicsthatincludedmusculoskeletalcomplaintsexperiencedinpa-tientswithGravesdiseaseandcontroversiesrelatedtopoorlydifferentiatedthyroidcancer.

ProfessorMiyauchigavemea tour of the hospital, an im-pressive facility thatprovidesmultidisciplinarycareforindi-vidualsdiagnosedwiththyroiddisease. I spent the morningwithProfessorMiyauchiinhisoutpatient clinic, reviewing a

Dr.WisemanwithhishostinKobe,ProfessorMiyauchi.


50

largenumberofpatientswiththyroid and parathyroid dis-ease.Thetopicsofdiscussionrangedfromsurgicalmanage-mentofmedullarycarcinomatotheuniqueexperienceattheKuma Hospital of long-termsurveillance for individualsdiagnosed with papillary mi-crocarcinoma.

Theafternoonwasspent intheORobservingseveraloftheskilledsurgeonsatKumaper-formingthyroidandparathy-roid operations. This experi-encewasinterestingandverydifferent from my experiencein North America, as thereweretwooperationsgoingonsimultaneously ineachsurgi-caltheater,anddoorsbetweenORsallowedmetoseeseveralotherthyroidoperationsoccur-ringsimultaneously.Iobservedseveral thyroidectomies forthyroidcancer, includingsev-eral lymph node dissections,several thyroidectomies forgoiter,andresectionofapara-thyroidcarcinoma.Alltheen-docrinesurgeonswerefriendlyandwehadmanydiscussionsfocusedontechnicalaspectsoftheirthyroidoperations.

Intheevening,therewasaresearch mini-symposium atwhichseveraloftheKumastaffgave presentations of theirworkthatwouldbepresentedat upcoming meetings. Thepresentation topics includedpoorly differentiated thyroidcancer and intrathyroid epi-thelial thymoma/carcinomashowingthymus-likedifferen-tiationlesions(anuncommonthyroid tumor originally de-scribedbyProfessorMiyauchiatKumaHospital).

Igaveapresentationonmo-

lecularmarkersforimprovingthyroidcancerdiagnosisatthissymposium.ThediscussionwasterrificandIansweredseveralquestionsonmyresearchthathasfocusedonanaplasticthy-roidcancer.ItwasapleasuretomeetandchatwithYasuhiroIto,MD,anendocrinesurgeonatKumawho,likemyself,hasaresearchinterestinthyroidcancermolecularbiology.

Beforemydeparture, Ihadtheopportunity to speak fur-therwithProfessorMiyauchionseveralothertopics,includ-ing a review of his techniqueof lateral mobilization of therecurrent laryngeal nerve tofacilitatetrachealresectioninpatients with thyroid cancerinvadingthetracheaneartheligamentofBerry.

Kobewasabeautifulcityandbefore Natalie and I left, wetook a ride on the Shin-Kobecablecartothetopofamoun-tainthathadabeautifulviewofboththecityandthesea.

NagasakiI then took the shinkansen

andtraintoNagasakiforthe108th annual congress of theJSS.Themeetingbeganwiththe council dinner, whereNatalie and I were warmlywelcomed by the president,Prof. Takashi Kanematsu,MD, and Ms. Kanematsu. Atthis dinner, we were seatedwith several members of thesociety,includingProf.KoichiTabayashi,MD,Prof.HiroshiTakami,Prof.AkiraKawagu-chi, and visiting pioneeringcardiac surgeon/conferencespeaker Randas J.V. Batista,MD, of Brazil. I was intro-duced to the members of the

society as the representativeof the American College ofSurgeons. I was very proudandhonoredtorepresenttheACSat thisevent. IalsometThomasR.Russell,MD,FACS,ACS Executive Director, whowas giving a lecture at theJSS congress, and SusumuEguchi,MD,PhD,FACS,whohadassistedmewithplanningmy visit. After dinner, I washonoredtobecongratulatedbymanymembersof thesocietyforbeingselectedastheTrav-elingFellow.

The JSS congress was heldattheNagasakiBrickHall,alarge conference center, andseveralmeetingsessionswereheld in surrounding hotels.Mypersonalhighlightsoftheconferenceincludedtheendo-crinesurgicalsessionchairedbyShigetoMaeda,MD,PhD.Iespeciallyenjoyedapresenta-tion given by Makoto Kam-mori,MD,PhD,ofTokyo,thatevaluatedthediagnosticutilityoftelomerelengthinfollicularthyroidlesions.

As part of the congress, Ialsogavealectureduringthissessiononmyresearchevalu-ating the molecular pheno-type of differentiated thyroidcancer. My lecture generatedan interestingdiscussionandseveral questions. Overall, itwasencouragingformetoseethat, like in North America,surgeon-scientists in Japanare carrying out excellentresearch.

Another highlight of theJSSformewastheminimallyinvasivethyroidsurgeryvideosession. Pioneers in a widevariety of minimally invasiveapproachestothyroidsurgery


51

Dr. Wiseman receiving a certificate commemorating his ACS TravelingFellowshiptoJapanfromProfessorTakamionbehalfoftheJapanSurgicalSociety.

presentedvideosanddiscussedtheir operative techniques. Iwas impressed with the inno-vation, resourcefulness, andtechnical expertise evident inthese videos. Other lecturesandpostersessionsIattendedattheJSScongressfurtherim-pressedmewiththehighlevelof scholarship maintained byJapanesesurgeons.IespeciallyenjoyedmeetingseveraloftheinternationalJSStravelgrantrecipients, and it was a greathonor being presented witha certificate from the JSS byProf. Hiroshi Takami to com-memoratemytravellingfellow-

ship(seephoto,thispage).Natalie and I very much

enjoyed the informal dinnerhostedbyShigetoMaeda,MD,PhD,andhis colleagues fromNagasaki University, that al-lowedmetochatwithmanyofthe endocrine surgeons Ihadmetonmytrip,includingProf.ShimizufromTokyo,YasuhiroIto from Kobe, Makoto Kam-morifromTokyo,andothers.I enjoyed speaking with Dr.Maeda about endocrine sur-geryinNagasaki.

WhilevisitingNagasaki,wehad the opportunity to visitseveraltouristsitesandwere

very moved by the Nagasakiatomicbombmuseumandme-morial.

BeppuMynextdestinationwasthe

Noguchi Thyroid Clinic andHospital in Beppu. Beppu isa quaint town known in Ja-pan for its many natural hotsprings.WhilevisitingtheNo-guchiHospital,IwashostedbyProf.ShiroNoguchi,MD,PhD,directorofthismedicalcenterthat,likeKuma,isfocusedonthyroiddisease.Iwasgreetedby Hitoshi Noguchi, MD, andShiroNoguchiuponmyarrival(seephotos,page53).InitiallyItouredaroundthisfacilityandwasshowntheinpatientwards,outpatientdepartment,radiol-ogy,andlaboratory.

Afterward, Hitoshi Noguchiand I spoke at length aboutmultiple issues related to themanagement of thyroid can-cer. I learned that, like me,hehadaninterestinstudyingnewtreatmentsforanaplasticthyroid cancer and he sharedwithmetheresultsofsomeofhisrecentstudy.Ialsogaveapresentation of my researchevaluatingnoveltreatmentsforanaplasticthyroidcancer.Thisgenerated many questions,stimulatedfurtherdiscussion,andwedecidedthatwewouldcollaborate in the future onanaplastic thyroid cancer-relatedresearchprojects.

Ispenttheafternoonobserv-ingseveralthyroidoperationscarriedoutbytheskilledendo-crinesurgeonsatthehospital.Iobservedseveraloperationsforbothbenignandmalignantthy-roiddisease,includingalocallyadvancedthyroidcancer,andit


52

wasveryexcitingformetoseethat for some thyroid surger-ies, an electrothermal vesselsealingsystemwasused.

Attheendoftheday,Ihadan opportunity to speak withShiroNoguchionseveraltopicsincluding the management ofpapillarymicrocarcinoma,andhowhehadrecently reportedthat tumors between 6 mmand10mmbehaveinafashionsimilar to larger tumors. Wealso discussed the extent oflymphadenectomy for thyroidcancer.

Themultidisciplinaryconfer-ence that followed reviewedmany interesting cases and Iwas impressed with the highlevel of scholarship displayedat this meeting. Beppu was abeautiful city and before our

departure, we had the oppor-tunity to visit their famousnaturalhotsprings.

ReflectionsOnthewaytotheairportin

Osaka, we visited the atomicbomb memorial in HiroshimaandspentadaytouringKyoto,oneofthemostbeautifulcitiesIhaveeverseen.Theimpres-sivebeautyofthemanyshrinesand gardens in Kyoto reallymustbeseentobebelieved.MyvisittoJapanwasaverybusybutawonderfulexperienceforNatalieandme.IfoundallmyJapanesecolleaguestobefan-tastichostsandtheirtechnicalexpertise,academicfocus,andsciencetobeataveryhighlev-el.IwholeheartedlythanktheAmericanCollegeofSurgeons

for the great honor of serv-ing as its representative andgiving me the opportunity tovisitseveralexcellentJapanesesurgical centers, to exchangeideas,tolearn,andtodevelopnew academic collaborationsandfriendships.

Dr. Wiseman is a surgical oncolo-gist, head and neck surgeon, gen-eral surgeon, and scientist in the department of surgery, St. Paul’s Hospital, University of British Columbia, Vancouver.

Dr.WisemanwithhishostsinBeppu,Prof.ShiroNoguchi(left)andDr.HitoshiNoguchi.


53

Programs accredited by the Commission on Cancer (CoC) of the American College of Surgeons make a commitment to their patients to invest their resources in the best available methods for the early detection and treatment of cancer. And the Commission is there–every step of the way–to help each accredited program meet the challenge.

The Commission on Cancer provides a model for managing your facility’s cancer program by:

Setting standards to promote high-quality, multidisciplinary patient care

Facilitating ongoing assessment of your program’s activities

Providing real-time access to National Cancer Data Base data to evaluate and improve your delivery of care

Even more, CoC-accreditation earns recognition from national health care organizations for meeting performance measures for high-quality cancer care. The American Cancer Society also acknowledges and supports the importance of CoC accreditation through its National Cancer Information Center and other patient-focused resources.

Patients rely on your facility to provide a comprehensive approach to their cancer care, and the Commission on Cancer can help your program provide access to the highest level of cancer care for your patients.

Is your cancer program ready?

Get ready. Learn about the Commission on Cancer Approvals Program today.

Visit the Commission’s Web site at: www.facs.org/cancerprograms/mh08Or send an E-mail query to: [email protected]

Administrator Ad 2008 full page 1 1 4/30/2008 1:22:17 PM

Theterm“medicaltourism”isgainingrecognitionintheU.S.asthemediaincreasinglyareshin-ing a spotlight on the growingtrendofAmericans,particularlythe uninsured, traveling over-seasforlow-costmedicalcare.

Asaresultofthistrend,TheJoint Commission’s interna-tional accrediting arm, JointCommissionInternational(JCI),isalsogarneringafairamountof attention. JCI is recognizedaround the world for its rigor-ous and comprehensive set ofinternational standards. JCI,a division of Joint Commis-sion Resources Inc. (JCR)—aprivate, not-for-profit affiliateofTheJointCommission—wasestablished in 1997 and beganaccrediting organizations out-sidetheU.S.in1999.JCIoffersaccreditationforhospitals,am-bulatory care facilities, clinicallaboratories, care continuumservices,primarycarefacilities,and medical transport organi-zations, aswell as certificationindisease-orcondition-specificcare. Today JCI accredits andcertifiesmorethan200organiza-tionsin33countries.

For Americans travelingabroad for medical treatment,whether an organization is ac-credited by JCI is one way toassess the quality and safetyof an organization where theyare considering undergoing aprocedure.

JCI’sstandards,training,andprocessesusedduringthesurveymeet the highest international

benchmarks for accreditation.Thestandardsandsurveypro-cesshavebeenadaptedfortheinternational community andaredesignedtobeculturallyap-plicableandincompliancewithlawsandregulationsincountriesoutsidetheU.S.Thestandardsweredevelopedbyinternationalexpertsandsetuniform,achiev-ableexpectationsforstructures,processes, and outcomes forhealth care organizations. Therequirements for accreditationalso include international pa-tient safety goals, which high-lightproblematicareasinhealthcareanddescribeevidenceandexpert-based consensus solu-tions to these problems. Thesurvey process is designed toaccommodate specific legal,religious, and cultural factorswithinacountry.

Although some of the orga-nizations accredited by JCIservemedicaltourists,thevastmajorityof thepatientsserved

atJCI-accreditedorganizationsare local residents. JCI helpscountrieseducateorganizationsandstaffonhowtoachieveim-proved quality and safety. JCIalsohelpsministriesofhealthtodeveloptheirownstandardsandestablish theirownaccreditingbodies.

JCIisaccreditedbytheInter-national Society for Quality inHealth Care and extends TheJoint Commission’s missionworldwide by assisting inter-national health care organiza-tions, public health agencies,healthministries,andotherstoimprove thequalityand safetyofpatientcareinmorethan80countries.JCIisheadquarteredinOakbrook,IL,andhasinterna-tionalofficeslocatedinFerney-Voltaire, France; Milan, Italy;Dubai,UAE;andSingapore.

FormoreinformationonJCI,visit www.jointcommission international.orgorcall630/268-7400.

AlookatTheJointCommission

International focus on accreditation

Thefollowingcontinuingmedi-caleducationcoursesintraumaarecosponsoredbytheAmericanCollege of Surgeons Committeeon Trauma and Regional Com-mittees:

• Advances in Trauma,De-cember12–13,KansasCity,MO.

• Trauma, Critical Care, & Acute Care Surgery–2009, April6–8,2009,LasVegas,NV.

• Trauma, Critical Care,

& Acute Care Surgery 2009–Point/Counterpoint XXVIII,June 8–10, 2009, Atlantic City,NJ.

Complete course informa-tioncanbeviewedonline(asitbecomesavailable)throughtheAmerican College of Surgeons’Web site at http://www.facs.org/trauma/cme/traumtgs.html,orcontacttheTraumaOfficeat312/202-5342.

Trauma meetings calendar


55

The famous Shakespeareanline (The Tempest) about illu-sionthatiscitedinthetitleofthis column seems appropriatetonewlaparoscopicprocedures.These procedures are receiv-ing gradual acceptance in oursurgical practice. This incre-mentalacceptanceofminimallyinvasivesurgery(MIS) ismorepronouncedwithcancerbecausethereareconcernsrelatedtoef-ficacyandsafetywhencomparedwithstandardsurgicalresection.Local control of primary ma-lignantdiseaseisapriorityforsurgeons who treat resectabledisease.Thisisofgreatestcon-cernwhenMISisconsideredforprimaryresectablerectalcancer.Aswithlaparoscopiccolectomy,laparoscopic approaches to lowanterior resection, coloanal re-section, and abdominoperinealresectionaretechnicallyfeasiblewithimprovedinstrumentationandgreatersurgeonskill.

Althoughmanyofuscanap-preciate the potential patientrecovery benefits of perform-ing these procedures, do theyachieve the same local cancercontrol rate of open resection?

ACOSOGnews

“Such stuff as dreams are made on”: Laparoscopic rectal cancer trialby David M. Ota, MD, FACS; and Heidi Nelson, MD, FACS

Only through a prospective,randomized trial design canwe answer this question andothers.

The American College ofSurgeons Oncology Group(ACOSOG) has recently acti-vatedprotocolZ6051,APhaseIII Prospective RandomizedTrial Comparing Laparoscop-ic-Assisted Resection versusOpenResectionforRectalCan-cer. The primary objective isto test the hypothesis thatlaparoscopic-assisted resectionforrectalcancerisnotinferiorto open rectal resection basedon pathologic analysis of theresectedspecimen.

This analysis will include acircumferential tumor margin>1mm,distalresectionmargin>2cm(or>1cmwithclearfro-zensectioninthelowrectum)andcompletenessoftransmeso-rectal excision. These are cru-cial benchmarks in evaluatingthequalityofsurgicalresectionofprimaryrectalcancer.

Secondary object ives ofthe trial include assessmentof patient-related benefit oflaparoscopic-assisted resectionfor rectal cancer versus openrectal resection (blood loss,length of stay, pain medicineutilization);assessmentofdis-ease-free survival and localpelvicrecurrenceattwoyears;and assessment of quality of

life,sexualfunction,andboweland stoma function at sched-uled time points throughoutthetrial.

Currently, there is no level Ievidence that laparoscopic re-sectionofrectalcancerproducesthe same histopathologic out-comecomparedwithopenresec-tion. Potential concerns withlaparoscopic resection includeless visualization of the pelvisandexposureofthemesorectumand adjacent structures, suchashypogastricnerves.Arecentprospective,randomizedtrialoflaparoscopicsurgeryforeithercolonorrectalcancersuggestedanincreasedriskofpositivecir-cumferentialradialmarginwiththe laparoscopic approach,*whichdidnotresultinahigherlocal recurrence, but the trialwasnotpoweredtoaddressthisissueinrectalcancer.

ThepatienteligibilitycriteriaforZ6051includethefollowing:

• Histologic diagnosis ofadenocarcinomaof therectum(<12cmfromtheanalverge)

• T3N0M0,TanyN1M0dis-easeasdeterminedbypretreat-ment computed tomographyscansandpelvicmagneticreso-nance imaging or transrectalultrasound; patients with T4disease extending to circum-ferential margin of rectum orinvading adjacent organs arenoteligible

*GuillouPJ,QuirkeP,ThorpeH,etal.Short-term endpoints of conventionalversus laparoscopic-assisted surgeryin patients with colorectal cancer(MRC CLASICC trial): Multicenter,randomized controlled trial. Lancet.2005;365:1718-1726.


56

• Completion of preopera-tive 5FU-based chemothera-py and/or radiation therapy;capecitabinemaybesubstitutedfor5FU

• Age>18years• Eastern Cooperative On-

cology Group (Zubrod) perfor-mancestatus<2

• Bodymassindex<34• Noevidenceof conditions

that would preclude use of alaparoscopic approach (for ex-ample,multiplepreviousmajorlaparotomies,severeadhesions)

• No systemicdisease (car-diovascular,renal,hepatic,andso forth) that would precludesurgery; no other severe, in-capacitating disease—that is,American Society of Anesthe-siologist classification of IV (apatient with severe systemicdiseasethatisaconstantthreattolife)orV(amoribundpatientwhoisnotexpectedtosurvivewithouttheoperation)

• Nonpregnantandnonlac-

tating,asconfirmedbypretreat-mentpregnancytestforpatientsofchildbearingpotential

• No concurrent or previ-ousinvasivepelvicmalignancy(cervical, uterine, and rectal)withinfiveyearsbeforeregis-tration

• No history of psychiatricoraddictivedisordersorotherconditionsthat, intheopinionof the investigator,wouldpre-cludethepatientfrommeetingthestudyrequirements

As with all ACOSOG proce-dure trials, there are surgeoncredentialing criteria to par-ticipateasaninvestigatorinthetrial. Credentialing in laparo-scopiccolonandrectalsurgeryare required. Credentialingforlaparoscopiccolectomyandlaparoscopicrectalsurgerybothrequire20laparoscopicorhand-assistedoperations.Laparoscop-iccasesforbenigntumorsornon-neoplastic diseases can be in-cludedincredentialingcases.

Further details are found inthe protocol, which can be ac-cessed on the ACOSOG Website (www.acosog.org). JamesFleshman,MD,FACS,protocol

studychair,[email protected].

Z6051 is very much a suc-cessortrialtothelaparoscopiccolectomytrial†butwithadif-ferent primary endpoint. Pro-spective phase III randomizedtrials for new procedures incancertreatmentareneededtodemonstrate that such techni-caladvancesarenotinferiortostandard procedures and thatthere is measurable improve-mentinqualityoflife.

TheNationalCancerInstitutehasdesignatedZ6051asahigh-priority trial. ACOSOG needsyour involvement in order forsurgeonstoestablishthevalid-ityandsafetyoftheprocedure.Asasurgeon-orientedcoopera-tive group, ACOSOG will con-tinue to develop and conductprocedure-oriented nationaltrials. To date, ACOSOG hasachieved considerable successwithsuchtrialsandthecommit-mentoftheACOSOGmembersisverymuchappreciated.

Dr. Ota, of Durham, NC, and Dr. Nelson, of Rochester, MN, are ACOSOG co-chairs.

†C l in ica l Outcomes o f Surg ica lTherapy Study Group. A comparisonof laparoscopically assisted and opencolectomy for colon cancer. N Engl J Med.2004;350:2050-2059.

The Board of Governors ofthe American College of Sur-geons is pleased to announcetheavailabilityofthe2009Ni-zarN.OweidaScholarship.TheOweidaScholarship,anannualawardadministeredbytheEx-ecutiveCommitteeoftheBoardofGovernors,wasestablishedin1998inmemoryofDr.Oweida,a general surgeon who prac-ticedinasmalltowninwestern

Pennsylvania. The purpose oftheOweidaScholarshipistoen-ableyoungsurgeonspracticinginruralcommunitiestoattendtheClinicalCongressandbenefitfromtheeducationalexperiencesit provides. The $5,000 awardsubsidizesattendanceatthean-nualClinicalCongress,includingpostgraduatecoursefees.

Applicationsconsistofacur-riculumvitaeplusaone-pagees-

saydescribingwhytheapplicantcharacterizeshisorherpracticeasruralandwhyheorshewouldlike to receive the scholarship.Thedeadlineforreceiptofappli-cationmaterialsisDecember15,2008.Forthecompleterequire-mentsforthisscholarship,visithttp://www.facs.org/member services/oweida.htmlorcontacttheScholarshipsAdministratoratkearly@facs.org.

2009 Oweida Scholarship availability announced


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$1,000,000

800,000

600,000

400,000

200,000

05 10 15 20 25 30 35 40years

Investmentafter 40years:$1,082,949

Investmentafter 30years:$405,821

• • • • ••

•

• • • • ••

•

•

Let the power of compounding work for you. You have worked hard and spent time and money to be where you are. Now you can put both time and money to work for you by investing $100 per month in an account with SDIF. Starting early on, a regular program of investing can make a tremendous difference over time. The charted hypothetical example illustrates the difference between two investors who invest identical amounts, starting with $100 per month, and increase their contributions by 10% each year. The chart assumes an average annual return of 6%, compounded monthly. The only difference is that one investor starts today, and the other starts 10 years from now. Forty years later, the investor who started early has a portfolio of more than $1 million. The investor who started later has only $400,000.

An investor should consider the investment objectives, risks, and charges and expenses of SDIF carefully before investing. SDIF’s prospectus contains this and other information about SDIF and should be read before investing. SDIF’s prospectus

may be obtained by downloading it from SDIF’s Web site at www.surgeonsfund.com or by calling 800/208-6070.

A program of regular investing does not ensure a profit or protect against depreciation in a declining market. Because a consistent investing program involves continuous investment in securities regardless of fluctuating prices,

you should consider your financial ability to continue to purchase through periods of various price levels.

SDIF is distributed by Ultimus Fund Distributors, LLC, 225 Pictoria Dr., Suite 450, Cincinnati, OH 45246. The phone number is 513/587-3400.

Assuming $100 invested per month, 10% annual increase in amount invested, and 6% average annual return.

This hypothetical does not represent the returns of any particular investment. An investment in the Fund may have very different results. Past performance is no guarantee of future returns.

take advantage of your greatest asset. invest now.

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For more information about SDIF, please contact: Savi Pai, 312/202-5056, [email protected] Kiley, 312/202-5019, [email protected] may also visit the Web site at www.surgeonsfund.com or call 800/208-6070.

SDIF| a member benefit fromtheamerican College ofsurgeons

Time is your GreaTesT asseT

Resident Compound Ad Final Art.i1 1 9/24/2008 2:49:08 PM

NTDB®datapoints

ATVs: “All-terrain victims”by Richard J. Fantus, MD, FACS

Number of incidents by age groupIt is now the middle of fall,

and all-terrain vehicle (ATV)use is in full gear. It is notuncommon in the Midwest tohear of an ATV-related fatal-ityonaregularbasisthistimeof year. According to the U.S.ConsumerProductSafetyCom-mission (CPSC), the numberof estimated injuries treatedin the emergency room hasalmost tripled over the mostrecent10-yearperiodforwhichdataareavailable,from53,500in 1996 to almost 150,000 in2006.Alongwiththisincreasednumberofinjurieshasbeenanestimated threefold increaseindeaths from267 in1996 to870 in 2006. In 2006, deathsin children younger than 16years of age accounted for ap-proximately 20 percent of thefatalities (http://www.atvsafety.gov/stats.html).

The CPSC has stated thatATVs are one of the deadliestproducts under their jurisdic-tion.Theagencyhasworkedfor20years trying tomakeATVssafer.Asidefromadecreeinthe1980stobanthesaleofthree-wheel models, there has beenvery little progress in recentyears.

In order to examine the po-tential occurrence of injuriessustainedwhileonanATV,theNational Trauma Data Bank®(NTDB) Dataset 7.1 recordswere searchedusing the Inter-national Classification of Dis-

eases, Ninth Revision, ClinicalModification cause of injurycode E 821, accident involvingoff-road motor vehicles (whichincludeATVs),andfurthersort-ed to identify injury to driver,821.0, or to passenger, 821.1.This search resulted in 58,235records, composed of 35,665drivers, 6,859 passengers, and15,711other/unspecified.Theserecordswerethendividedtoas-sesstheagesofvictimsintheseincidents.TherewasanincreaseinincidentsamongyoungerATVusers.Thesedataaredepictedinthegraphonthispage.

The Specialty Vehicle Insti-tuteofAmericapointsoutthatavastmajorityoftheATV-relatedaccidentsandfatalitiesinvolverider error. There is a chasmbetween the industry and theprotection agency. There aresomevaluableprecautionsonecan take in order to mitigatepotential injury, such as keep-ingthevehicleoffpavedroads,avoidingtandemrides,wearingahelmet,notdrivingundertheinfluence of alcohol, and notallowing children to operateadult-sizedATVs.Totakeitonestepfurther,theAmericanAs-


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sociationofPediatricssuggeststhatnochildrenyoungerthan16yearsdriveATVsregardlessof the model and whether anautomobile driver’s license isrequiredtooperateone.

We all make choices in life,and if one of yours puts youonthebackofanATV,besuretoheedtheabovesoyourATVwill not stand for “all-terrainvictim.”

ThefullNTDBAnnual Report

Version 7.0 is available on theACSWeb site as aPDFandaPowerPoint presentation athttp://www.ntdb.org.

Ifyouare interested in sub-mitting your trauma center’sdata, contactMelanieL.Neal,Manager, NTDB, at [email protected].

Acknowledgment

Statisticalsupportforthisarticle

has been provided by Sandra M.Goble,MS.

Dr. Fantus is director, trauma services, and chief, section of surgical critical care, Advocate Illinois Masonic Medical Center, and clinical professor of surgery, University of Illinois College of Medicine, Chicago, IL. He is Chair of the ad hoc Trauma Registry Ad-visory Committee of the Committee on Trauma.


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ACS Practice Patterns Survey, Part II

Documents

Transcript of ACS Practice Patterns Survey, Part II