Trauma and Critical Care Training:  What was I thinking?

At some point in 2004, I walked out of the Univeristy of New Mexico Hospital with a smile on my face.  I had just completed my last day on the trauma service.  No longer would I be up in the middle of the night taking care of labor-intensive injured patients.  No longer would I sit for hours in the ICU taking care of the sickest of sick patients while others operated on the “interesting cases.” My career path was taking me towards the aspect of surgery that I loved the most- operating, operating, operating.  I was happy to be in the OR all day while critical care specialists helped take care of the sicker patients whose care I was involved in.
I spent the first decade of my career as a busy, private practice surgeon which meant I spent a lot of time in the operating room.  I loved it.  But as our family transitioned to Kenya it became very apparent that good outcomes in complex surgical patients at Tenwek were hard earned.  Yes, a technically perfect operation is imperative, however,  a good outcome depends on much more than just a good operation.  Technically difficult operations could be completed, however, patients who became sick after these procedures or who were admitted to the ICU after life threatening trauma often times died when they shouldn’t have.  Was it my care?  Was it the residents’ lack of knowledge of critical care medicine?  Was it our monitoring capabilities?  Was it nursing?  Was it specific problems in our rural Kenyan population?  The answer to all of these questions was yes.  And there are many more problems.  The bottom line is that it is largely a systems issue.  We as physicians like to tackle specific diseases and problems, but we often times neglect the development of a system of care that can be applied to a broad range of patients.   It became clear to me that we can  teach our residents how to be expert operators- even at advanced techniques such as laparoscopy that are rare in rural Africa. However, until we develop a better system for caring for the critically ill, outcomes in our sickest patients are not likely to change.

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As our first term in Kenya was coming to an end in June of 2016, we began to think about how we would spend our time in the U.S.  Angela and I had decided that we wanted the girls back in school for a complete school year.  Angela wanted to mainly focus on helping the girls transition back to the U.S., and I hoped to be able to work.  But as I thought about working, I felt like my time would be best spent by trying to learn things that I could take back to Kenya.  We discussed the possibility of me doing a fellowship in surgical critical care and ultimately decided to ask around to see if there were any available fellowships spots.  Fellowships are additional training programs that physicians can do once they have completed a residency.  To be a cardiologist, one does a fellowship after a medicine residency.  To be a heart surgeon, surgeons will do a 2 or 3 year fellowship after their general surgery residency.  Surgeons can do a year of specialized training in surgical critical care which prepares one to care for the sickest of sick surgery patients.  In practice, most surgical critical care specialists are also trauma surgeons due to the fact that traumatized patients often make up a large percentage of patients in a surgical ICU.  In the current era, the evolving specialty of acute care surgery has emerged, which encompasses surgical critical care, emergency general surgery, and trauma surgery (which makes up a huge chunk of what we do at Tenwek).  Most practitioners of this specialty in teaching facilities are board certified in surgical critical care.  And so, my hope was to find a fellowship which would allow me to do this.

 

After sending out multiple inquiries, we were delighted to hear that the program at the Univerisity of Tennessee in Knoxville was willing to allow me to join them for a year as one of their surgical critical care fellows.   I couldn’t be more grateful to the trauma and critical care faculty at UT who helped create a spot for me.  They allowed me the freedom to spend time learning skills would be beneficial to the work at Tenwek.  I was even able to spend a month at Parkwest Hospital (the hospital were I worked prior to going overseas) working with the cardiac anasthesiologists learning how to take care of cardiac surgery patients.  However, the year of training had its struggles.  I felt all of my 43 years of age during the busy call nights.  Recovery after these busy call nights took an extra day or two more than it used to.  Time with our family was more limited than we had hoped after being away for a couple of years.  However, it was a privilege to have the opportunity to sink my teeth into learning the nuances of trauma and critical care surgery.
Now as we transition back to Tenwek I am looking forward to putting new knowledge to work.  Like many other areas of medicine, modern critical care capabilities are lagging in the developing world.  In Kenya, there are nicely developed critical care units in some of the larger hospitals in Nairobi, however, distance, money, and transportation issues limit access to these facilities for a large percentage of the population.  Fortunately, the need for surgical ICU development in low and middle-income countries is  increasingly recognized.  A nice article by Drs. MacLeod, Kirton, and Maerz was published in 2016 highlighting the incredible need for critical care development as well as possibilities for a way forward in development.  Here is the link to this article for all of you as nerdy as me: Surgical Intensivist and global critical care: is there a role?  The authors point out staggering statistics such as the fact that 90% of deaths due to trauma world-wide occur in low and middle-income countries. Each year, 8 to 10 million children under the age of 5 die, however, 90% of these deaths occur in the 42 poorest countries.  Many of these deaths could be prevented by access to critical care services.  Although ICU’s in the west are often thought of has being high-tech, expensive, sophisticated units, the authors correctly point out that major improvements in patient outcomes can be achieved by implementing basic tenets of critical care.  It is my hope to continue to make improvements in the way we deliver surgical critical care in our relatively rural setting at Tenwek, but more importantly, to educate our residents so that when they leave our program they are capable of ministering to the sickest of sick.

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