Emergency Surgery in Europe Jonathan Tilsed

1. Emergency Surgery in Europe Jonathan Tilsed Chairman UEMS Division of Emergency Surgery President European Society for Trauma and Emergency Surgery

2. Emergency surgery in Europe • Background • Differences • Common problems • Solutions

3. Background

4. uneducated illiterate hair cutting teeth – pulling blood letting simple operations war wounded

5. Feared the church more than the courts:

6. Progress was slow:

7. Every important hospital should have on its resident staff of surgeons at least one who is well and able to deal with any emergency that may arise William S. Halsted (1852-1922)

8. 19th & early 20th century

9. 1940s 1960s European history - conflict 1970s 1990s

10. Delivering care: right skills & right system

11. Differences

12. Where are we now? • general surgeon • visceral surgeon • ‘unfallchirurg’ • acute care surgeon

13. Acute Care Surgery in Europe: a) Skeletal trauma • Orthopedist(Finland, France, Italy, Norway, Portugal, Romania, Spain, Turkey and United Kingdom) • A trauma or general surgeon (Croatia, Luxembourg, and The Netherlands) • A trauma or orthopedic surgeon (Czech Republic and Germany) • General surgeon (Greece and Switzerland) b) Visceral trauma • General surgeon (Austria, Croatia, Finland, Greece, France, Italy, Luxembourg, The Netherlands, Norway, Portugal, Romania, Switzerland, Spain, Turkey, and United Kingdom) • Visceral and/or trauma surgeon (Czech Republic, Germany, and Slovenia) c) Abdominal emergencies • General surgeons (Austria, Croatia, Greece, Finland, Italy, Luxembourg, The Netherlands, Norway, Portugal, Romania, Spain, Switzerland, Turkey and United Kingdom) • Visceral/abdominal surgeons (Czech Republic and France) • Visceral/trauma surgeon (Germany, The Netherlands, and Slovenia) • Traumatologist/trauma surgeon (Austria and Slovenia) d) Thoracic emergencies • Thorax surgeons (Czech Republic and Finland) • Thorax or general surgeons (Austria, Croatia, Greece, Italy, Portugal, Romania, United Kingdom) • Visceral surgeons (France) • Trauma or thorax surgeons (Germany, The Netherlands, and Slovenia) • General surgeons (Norway, Spain, Switzerland, and Turkey) e) Vascular emergencies • Vascular surgeons (Czech Republic, Finland, Greece, Italy, Spain and United Kingdom) • Vascular or general surgeons (Austria, Croatia, Luxembourg, Portugal, Romania, Slovenia, Switzerland, and Turkey) • Visceral, orthopedic or vascular surgeons (France) • Trauma or vascular surgeons (Germany and The Netherlands) • General surgeons (Norway)

15. 10 questions • which country ? • who operates on: • skeletal injuries • visceral injuries • vascular injuries • chest injuries • head injuries • burn injuries • urinary tract injuries • the Acute abdomen • who manages the polytrauma or acutely ill surgical patient on ITU ?

16. 10 responses • country – drop down box • trauma surgeon • general surgeon • acute care surgeon • vascular surgeon • thoracic surgeon • plastic surgeon • neurosurgeon • anaesthetist/intensivist • other – free text

17. Survey • questionnaire to 102 contacts • 61 replies • 52 countries • 43 unique responses!

19. 52 countries surveyed

20. Who is the emergency surgeon?

21. Highly specialised (19%)

22. What about the Acute Care Surgeon? • Switzerland: does everything • USA: general surgeon who does burns & ITU • Sweden: same as general surgeon except no burns • Moldova: same as trauma surgeon • Sudan: skeletal injury only • Italy: no skeletal or intracranial trauma • UAE: no urological or intracranial trauma • Jordan ITU only – non-operative & Australia:

23. What can they do?

24. Urgent: within 6 hours Even acute care surgery has distinctions: Emergencies: immediate threat to life, limb or organ

25. Mortality after surgery in Europe: a 7 day cohort studyPearse RM Moreno RP Bauer P Pelosi P Metnitz P Spies C Benoit V Vincent J-L Hoeft A Rhode A Lancet. 2012 Sep 22;380(9847):1059–1065 EUSOS 498 hospitals and 28 European Nations • N = 46,539 patients, 1855 (4%) died before hospital discharge • 3599 (8%) were admitted to critical care -median length of stay of 1·2 days (IQR 0·9–3·6) • 1358 (73%) patients who died were not admitted to critical care at any stage after surgery • Crude mortality rates varied widely between countries (from 1·2% [95% CI 0·0–3·0] for Iceland to 21·5% [16·9–26·2] for Latvia). 

26. Common problems

27. free movement of medical specialists within the EU

28. Acute Care Surgery in Europe:

29. The Cinderella specialty Elective surgery: Emergency general surgery:

30. Who are the surgeons “on call” for Surgical Emergencies? USUALLY A “CONTRACTUAL OBLIGATION”

31. Trauma & Emergency Surgery Interface: 5 Academic Medical Centers

32. Trauma & EmergencySurgery Interface • General surgeon covers major trauma & EGS • Orthopaedics - musculoskeletal trauma • Trauma team leader: • GeneralSurgeon - Sweden, Finland & Norway • Emergency Medicine - Estonia • Anaesthetist - Denmark

33. Copenhagen, Denmark Oslo, Norway Stockholm, Sweden Helsinki, Finland Tallinn, Estonia

34. Current scope of Trauma andEmergencySurgery • Trauma and emergency surgery cases are treatedby standard general surgeons nationwide on duty, inaddition to their elective general surgery workload • Increasing tendency towards subspecialization insurgery; such as colorectal, upper gastrointestinal,endocrine, laparoscopic surgery, also diminishedthe work spectrum of a standard general surgeon

35. Surgical delay is a critical determinant of survival in perforated peptic ulcerMøller MH; Danish Clinical Register of Emergency Surgery 2013 • Of 2668 patients,708 patients (26·5%) died within 30 days of surgery • 67·5 per cent of the patients (1800 of 2668) had at least one of six co-morbid diseases • Every hour of delay from admission to surgery was associated with a 2·4% decreased probability of survival compared with the previous hour • 45·6 per cent had an ASA fitness grade of III or more • Limiting surgical delay in patients with PPU seems of paramount importance

36. Br J Surg 2013 Sep;100(10):1318-25. doi: 10.1002/bjs.9208. Epub 2013 Jul 17.Mortality in high-risk emergency general surgical admissions..Symons NR Moortha K Almoudaris AM Bottle A Avlin P Vincent CA Faiz OD HES data England • 367,796 patients admitted to 145 hospitals • 30-day mortality rate was 15·6 %(9·2-18·2%) • 14 and 24 hospitals were identified as high or low-mortality  • ITU, HDU and use of CT related to low mortality

37. Mortality of EGS patients & association with hospital structures and processesOzdemir BA Sinha S Pearse RM – English HES study BJA (2016) • 294,602 emergency admissions • 30 day mortality 4.2% (1.6% - 8%) • Low mortality related to high medical & nursing levels, greater operating theatre and critical care availability • High mortality related to WEEKENDS, fewer general surgery doctors and lower nursing ratios • Best hospitals had highest complications • Worst hospitals had fewest complications • FTR – failure to rescue

38. Solutions

39. I suppose Ireland is the best place in the world for directions. People will say to you "I wouldn't start from here if I were you." Dave Allen 1936-2005

40. Training • Resources • Systems • Outcome measures

41. THE FUTURE OF EMERGENCY GENERAL SURGERYAssociation of Coloproctology of Great Britain and Ireland, Association of Upper Gastro-intestinal Surgeons & Association of Surgeons of Great Britain and Ireland • infrastructure to support EGS • diagnostic and interventional radiology 24/7 • critical care support for all emergency laparotomy patients • 24 hr access to emergency theatres and daily urgent theatre lists • designated Lead Consultant for EGS

42. Cross Border Co-operation Boundless Trauma Care Central Europe (BTCCE) Agreement covering cross border areas of : Netherlands Germany France

43. Interhospital Transfers of Acute Care Surgery Patients: Should Care for NonTraumaticSurgical Emergencies be Regionalized?World Journal of Surgery December 2011, Volume 35,Issue 12, pp 2660-266715 October 2011Heena P. SantrySumbalJanjua, Yuchiao Chang, Laurie Petrovick, George C. Velmahos • Transferred patients comprised a significant portion of the population with major NTSEs admitted to the acute care surgery service of our tertiary centre • They presented with greater physiological derangement and had worse outcomes than DIRECT patients • As is currently established for trauma care, regionalization of care for NTSEs should be considered.

44. Learn from trauma care? • Pre-hospital • Hospital • Rehabilitation • Acute physiology team • Networks • European Registry Seamless care

45. Future direction? • Europe wide EGS registry • Common EGS guidelines • Risk adjusted surgical outcome data for all surgeons • EBSQ (EmSurg) standard requirement • Monitor EGS training across Europe • European directives for: perioperative care, medical and nursing staffing, access to theatre etc

46. Conclusion • Different training programmes • Different systems of delivery of care • Common problems • European approach may help solve them