Emergency Nursing Intervention and the Outcome towards Trauma Patients in the Emergency Department: A Scoping Review

Health disparities in regional anesthesia and analgesia for the management of acute pain in trauma patients.

Background In every emergency department (ED), pain is the most common chief complaint, especially among trauma patients. However, two-thirds of trauma patients are discharged from EDs with moderate to severe pain. Therefore, pain management is an important part of care in trauma patients in the ED. According to a study, 27% of trauma patients were discharged although they still felt pain, and 48% of patients were not reassessed. Previous studies have reported inadequate pain control in the ED, and pain is frequently requested to be eliminated by patients despite their conditions. To our knowledge, our study is the first of a kind that addresses pain management among trauma patients in the ED in the Kingdom of Saudi Arabia. The objectives of the study were to: Determine whether trauma patients receive pain assessment and/or reassessment. Determine whether trauma patients receive the proper pharmacological and/or non–pharmacological intervention to relieve their pain (according to clinical practice guidelines of King Abdulaziz Medical City [KAMC]). Relate triage score to appropriate pain management. Measure the differences between male and female responses towards pain management. Methods This retrospective cohort study included all adult trauma patients who attended the ED at King Abdulaziz Medical City in Jeddah from the period June 2016 to July 2018. Sample size was calculated based on the number of trauma patients presenting to the ED and 403 files were reviewed. After excluding any patients younger than 18 years old, intubated patients, and patients with GCS level below 13, the number of remaining patients was 332. Data were collected from the health information system (BestCare). Data were analyzed using SPSS version 24. Results Our results showed that the mean difference between pain scores before and after pain management is 1, which is not clinically significant. The percentages of patients that were not assessed or reassessed were 31% and 29%, respectively. The median time between arrival and initial assessment was approximately 19 minutes. The percentage of patients who were administered the right drug was 36.7%. The triage scores were not aligned with their conditions. There was no statistical difference between males’ and females’ change in pain score. Conclusion Compliance to pain assessment and reassessment in trauma patients is suboptimal. This reflects on the management of pain in trauma patients. Furthermore, appropriate pain management in relation to pain scores was also suboptimal. Knowing the negative short-term and long-term effects of poor pain management in this subset of patients raises the need for improvement using pain assessment and management tools. We recommend staff education of the importance of pain management. Additionally, a quality improvement project is recommended to enhance pain management in trauma patients. Further studies should be carried out in the Kingdom in different centers for trauma and non-trauma patients to assess and improve the performance in this important aspect. Relating this to patient satisfaction and long-term consequences is also recommended.

To evaluate whether the double cannula urethral stents (DCUS) are superior to traditional silicone Foley catheters (FC) or gastric tubes (GT) in hypospadias repair to decrease complications. This retrospective cohort study included 224 patients with hypospadias who underwent placement with DCUS (group DCUS), FC (group FC), and GT (group GT) after hypospadias repair between August 2019 and June 2023. The occurrence of early and late complications was assessed. The occurrence of complications in the three groups was compared, and the important contributing factors of urinary fistula and glans dehiscence were determined. A total of 224 patients, 86 in FC, 59 in GT, and 79 in the DCUS group, met the inclusion criteria. Postoperative early complications in the DCUS group were significantly lower than those in the FC group (P = 0.002), but there was no significant difference between the GT and FC group (P = 0.390), or between the GT and DCUS group (P = 0.065). Postoperative late complications in the DCUS group were significantly lower than those in the FC group (P = 0.040), and there was no significant difference between the GT and FC group (P = 0.422), or between the GT and DCUS group (P = 0.325). Logistic regression showed that age (p = 0.030) and stent type (p = 0.048) were important risk factors for urethral fistula, while glans width (p = 0.016) was an important risk factor for glans dehiscence. DCUS reduced the occurrence of complications compare to FC and GT after hypospadias repair, offering practical value for clinical application.

Evidence-Based Practice Guidelines for Trauma Care

Endotracheal intubation is essential for airway management in trauma patients but may cause hemodynamic instability and delay critical resuscitation measures. Recent studies have suggested that emergency department (ED) intubation may be linked with higher mortality compared to operating room (OR) intubation in trauma patients. However, it remains unclear if these findings apply to broader trauma populations, including both civilian and military patients. This study uses a nationwide trauma registry to test the hypothesis that ED intubation is associated with higher in-hospital mortality among major trauma patients, compared to OR intubation. Registry-based analysis of the Israeli National Trauma Registry evaluating major trauma (Injury Severity Score [ISS] ≥16) patients requiring hemorrhage control surgery between 2016 and 2023. ED intubation was the main exposure variable with in-hospital mortality serving as the primary outcome. Multivariable logistic regression and propensity score matching were applied to adjust for confounders, including injury severity, ED vital signs, penetrating injury, and blood product administration. The study included 975 patients, 470 (48.2%) of whom were intubated in the ED. ED-intubated patients had significantly higher ISS and higher proportion of profound shock compared to those intubated in the OR. In-hospital mortality was more common among patients intubated in the ED (22.6%) as compared with those intubated in the OR (8.5%). In the unadjusted logistic regression, ED intubation was associated with higher odds of in-hospital mortality (OR: 3.13, 95% confidence interval [CI], 2.15-4.62). However, after adjusting for several potential confounders, the association became nonsignificant and was persistent across sensitivity subgroup analyses. Propensity score matching resulted in 1:1 matching of 271 patients in each group, balancing characteristics such as ISS, profound shock, Glasgow Coma Scale, and penetrating injury. After matching, the mortality rate was similar between groups (12.5% for ED intubation vs 12.2% for OR intubation). In the matched cohort, logistic regression demonstrated no significant association between ED intubation and in-hospital mortality (OR: 0.97, 95% CI, 0.58-1.61). ED intubation was associated with a greater than 2-fold increase in odds of ICU admission in adjusted and propensity score-matched analyses. ED intubation was not significantly associated with increased in-hospital mortality after controlling for injury severity and shock. These findings suggest that while ED intubation may be more frequent in severely injured patients, its independent impact on mortality in patients undergoing emergent surgery remains unclear, warranting further prospective investigation.

BackgroundThe use of indwelling urinary catheters (IUCs) is thought to be the most significant risk factor for developing nosocomial urinary tract infections (UTIs). However, it is unclear how many elderly patients have preexisting bacteriuria prior to IUC placement. The purpose of this study was to determine 1) the frequency and appropriateness of IUC use in the Emergency Department (ED) in elderly patients admitted to our acute care hospital, 2) the percentage of elderly patients with an IUC who were discharged from the hospital with a diagnosis of UTI, 3) the percentage of patients with IUCs who were diagnosed and treated for UTI in the ED or who had admission bacteriuria ≥105 organisms/ml indicating preexisting UTI, and 4) the percentage of patients with no indication of UTI on admission who had inappropriately placed IUCs and subsequently were diagnosed with a UTI.MethodsRetrospective chart review. Chi square used to test significance of differences in proportions.ResultsSeventy three percent of patients who received an IUC in the ED were elderly (≥65 years old). During the study period, 277 elderly patients received an IUC prior to admission. Of these, 77 (28%) were diagnosed with UTI during their hospitalization. Fifty three (69%) of those diagnosed with a UTI by discharge either had the UTI diagnosed in the ED or had bacteriuria ≥105 organisms/ml prior to IUC placement. Of the 24 elderly patients who developed a catheter-associated UTI (i.e., 9% of the elderly population who received an IUC), 11 of the IUCs were placed inappropriately. Thus, 4% of elderly patients with no indication of UTI on admission who received an inappropriate IUC in the ED had a primary or secondary diagnosis of UTI by discharge. The overall rate of nosocomial UTI due to an inappropriately placed IUC was the same in males and females.ConclusionThis study indicates that the strong association between IUC use and UTI may be partly explained by the high prevalence of preexisting UTI prior to IUC placement. Further prospective studies are needed to clarify the true risk vs benefit ratio for IUC use in acutely ill elderly patients.

Background: Traumatic injuries are the major destructive causes of human disability and in some situations, they could cause mortality. Preparing an appropriate procedure for the management and treatment of trauma patients is still a big challenge. Anyway, through immediate diagnosis and management of trauma patients in emergency departments mainly in trauma golden hour most appropriate outcomes could be achieved. The initial examination of trauma patients should be carried out in the trauma golden hour by most appropriate diagnosis equipment prepared in the emergency trauma care unit. Objective: The present study was performed for reviewing the most appropriate techniques and equipment of diagnosis and management of traumatic injuries. Material and Method: For obtaining the most appropriate outcomes, a comprehensive review carried out through the general medical databases of PubMed, Embase, Google Scholar, MEDLINE, databases of Cochrane Library, Allied and Complementary Medicine Database and Allied Health Literature of CINAHL on care system of patients who suffer from various kinds of trauma were searched up to March 2020. Finally, the total number of 73 articles were selected for reviewing the newest available data around the main objective of the present study. Results: Trauma patients who detected with serious injuries in their vital organs should be managed through an appropriate standardized guideline. This comprehensive guideline is categorized into fourteen critical steps that provide general information about the importance, objective, initial actions, required equipment and staff and also the overall knowledge of any step in diagnosis and management of trauma patients. Conclusion: The prepared comprehensive guideline for appropriate management of trauma patients is a precise effective method for immediate management of trauma patients in trauma care units of emergency departments. The most critical situation such as severely injured patients, airway management, protecting breathing and circulation, major neurologic problems and the difficulties with clinical examination of whole-body could be managed through following the prepared guideline.

Reduction of CAUTI rates organization wide begins in the Emergency Department

Reducing Indwelling Urinary Catheter Use in the Emergency Department: A Successful Quality-Improvement Initiative

215 A Novel Clinical Protocol for Placement and Management of Indwelling Urinary Catheters in Older Adults in the Emergency Department: Implementation and Impact Assessment

Introduction: In Emergency Department (ED) polytrauma patients accept emergency nursing care and follows a complete diagnostic procedure and therapy. The required time is called time to treatment-length of stay trauma patients in ED. Aim: The aim of the present study was the registry of the trauma patient management and treatment to the ED of a public general hospital in Attica. Material and Methods: The studied sample consisted of 95 trauma patients aged over 14 years old with Injury Severity Score >15 (ISS>15) who were admitted to the ED of a general hospital in Athens and having to complete the whole diagnosis and treatment in the ED from February of 2014 until January of 2015. Data analysis was performed with the statistical package SPSS ver. 19. Results: The majority of the trauma patients were Greek men aged until 45 years old. The first reason of transportation was traffic accident, drifting was the second reason. The mean time of trauma patients at ED until their admission to the appropriate clinic, was 3, 3 hours (210 min), and has been influenced by the diagnostic tests time, the diagnostic tools and the number of the doctors, per major, who have been concerned the trauma patient. The Injury Severity Score has been influenced by the number of the doctors per major, the method of diagnosis and the admission to the appropriate department. The trauma patients who were not wearing seat belt and drifting, have the most seriously trauma according to the ISS. From the Patients who had 3-8 Glasgow Coma Scale the 45.5% (n:5) had admitted to Intensive Care Unit, respectively the 18.2% (n:2) had admitted at neurosurgery and surgery clinic. Conclusions: Polytrauma patient residence time to the Emergency Department is determinant and directly related with mortality and the overall outcome of the polytrauma patient during his hospitalization

Commentary: Emerging Crash Avoidance Technology: What Does It Mean to My ED?

Management of acutely injured trauma patients is one of the most advanced clinical competencies required by a trauma care team physician. In the United States, the majority of multispecialty trauma care training of anesthesiology residents occurs at level 1 trauma centers. These are primarily academic teaching hospitals with a high trauma case volume, that admits severely injured patients, and who provides 24-hour in-house coverage of anesthesiology services. The anesthesiology service plays an integral role in the management of severely injured patients.1 In contrast to the training, according to the National Anesthesia Clinical Outcome Registry (NACOR) from the Anesthesia Quality Institute (AQI), most trauma and emergency patients are cared for at nonacademic, medium-sized community hospitals.2 All anesthesiologists should acquire the basics of resuscitation for a patient after traumatic injury because even those clinicians who do not practice at level 1 trauma centers may still care for patients with traumatic injuries after residency.2 Trauma anesthesiology (TA) education during residency has been under-recognized and underemphasized. Currently, anesthesiology residency programs offer rotations in a variety of anesthesia subspecialties including ambulatory, transplant, neurosurgery, cardiothoracic, vascular, pediatric, regional, pain management, critical care, and even bariatric surgery. However, a trauma rotation is typically not offered. The Residency Review Committee (RRC) of the American Board of Anesthesiology (ABA) has established that residents must achieve competence in the delivery of anesthetic care for a minimum 20 patients “undergoing procedures for complex, immediate life-threatening pathology,” which may include trauma. The RRC, however, does not specify a minimum number of trauma cases nor the trauma knowledge or skills to be acquired. The mission statement of the ABA declares: “Because of the nature of anesthesiology, the ABA diplomate must be able to manage emergent life-threatening situations in an independent and timely fashion.”3 Nevertheless, the content outline of the (ABA/American Society of Anesthesiologists [ASA]) Joint Council on In-Training Examinations does not offer guidance on a trauma curriculum for anesthesiology training programs to be followed. As a result, many anesthesiology residents graduate with a lack of experience, confidence, and the ability to resuscitate patients with life-threatening or multiorgan trauma. Given the high number of graduating residents who may provide care for trauma patients in the private and community practice, adequate trauma and acute care education should be offered to equip them with the skills and knowledge to care for polytrauma patients. Committee on Trauma and Emergency Preparedness (COTEP) believes that there is an insufficient emphasis on trauma training in anesthesiology residency programs and that the knowledge and skills of graduating residents for managing trauma patients are inadequate and below international standards. For example, TA training has been described in detail in the Royal College of Anesthetists advanced level training manual since 2010.4 We believe that there is a need for focused training and education on managing trauma patients during residency training. To explore the attitudes of anesthesiologists regarding the need for training in TA, we solicited opinions of anesthesiology residents, residency program directors (PDs) and practicing anesthesiologists. Additionally, we invited trauma surgeons to share their views of anesthesiologists’ performance in trauma cases and their thoughts on implementing a dedicated TA curriculum. METHODS Four different online survey questionnaires were sent via SurveyMonkey (Palo Alto, California) to 4 groups of participants. Responses for all participants were anonymous. Anesthesiology residents: Chief residents from 133 US anesthesiology residency programs were contacted and asked to distribute the resident survey to the categorical residents (CA-1, CA-2, and CA-3) at their programs. Anesthesiology residency PDs: The PD survey was distributed to 133 PDs via e-mail. Practicing anesthesiologists: We asked presidents and/or secretaries of all the anesthesiology state component societies to distribute the survey to their members. Trauma surgeons: The survey was e-mailed to all members of Western Trauma Association (WTA) and active, senior, and associate members of the Eastern Association for Surgery of Trauma (EAST). Survey questions for all groups were designed by the ASA COTEP. The questions related to the following: Demographics (year of residency training) Availability and duration of residency training at a level 1 trauma center Availability of a formal TA rotation and curriculum Participants’ exposure to trauma during their residency and perceived benefit of a TA rotation for their education and practice Trauma surgeons were also asked to comment on the importance of the anesthesiologist’s role as part of the trauma team, as well as their opinion on anesthesiologists’ adequacy of training when managing trauma patients. The surgeons were also asked to comment on anesthesiologists’ skills and knowledge in trauma care. The surveys were designed to take <5 minutes to complete and consisted of 6 to 8 questions. All responses were anonymous. Completion of survey was voluntary and without remuneration. We applied descriptive statistics to evaluate our result. Results are expressed as number (%) and the lower and upper limits of 95% confidence intervals were calculated. The qualitative data collected as free-text comments were analyzed for thematic content. Institutional review board exemption status was requested by the EAST Research and Scholarship Section; therefore, the survey was reviewed by the Medical College of Wisconsin institutional review board and was deemed exempt from further review. RESULTS The response rates for the surveyed groups were as follows: Residents: Of the total 4652 US categorical residents (2014–2015 Accreditation Council for Graduate Medical Education [ACGME] data book), 212 residents completed the survey (4.5% response rate). Among the respondents, 28% identified themselves as CA-1, 37% as CA-2, and 34% as CA-3 residents. Program directors: We received 35 responses from 133 PDs (26.3% response rate). Practicing anesthesiologists: Of the 49 anesthesiology state societies (Alaskan state society’s email was invalid), which consisted of 31 389 active members, 433 practicing anesthesiologists responded (1.4% response rate). Trauma surgeons: Of the 1937 WTA and EAST members, 455 responded (23.5% response rate); 95% (430/454) were surgeons, 0.9% (4/454) emergency medicine physicians, 1.5% (7/454) anesthesiologists, 2.2% (10/454) nonphysicians, and 0.66% (3/454) other. The results of the surveys are presented in the Tables 1, 2, 3, and 4 and Supplementary survey result charts for residents, PDs, anesthesiologists, and surgeons (Supplemental Digital Content 1–4, Figures 1–4, https://links.lww.com/AA/B901, https://links.lww.com/AA/B902, https://links.lww.com/AA/B903, https://links.lww.com/AA/B904).Table 1.: Survey Results: ResidentsTable 2.: Survey Results: Program DirectorsTable 3.: Survey Results: Practicing AnesthesiologistsTable 4.: Survey Results: Trauma Surgeons Residents: A clear majority of residents (98.6%) reported having their training at a level 1 trauma center and 81.5% felt they had sufficient exposure to emergency surgery for life-threatening or multiorgan trauma; 40.5% of them had a formal rotation in TA. The majority of the residents saw a benefit of trauma rotation for their education (87%) and for their future practice (76.5%). Program directors: Most of the PDs (94.3%) reported their training occurring at the level 1 trauma center and 81.3% believed that their residents had sufficient exposure to emergency surgery for life-threatening or multiorgan trauma; 41.9% offered a formal TA curriculum but only 20% offered a formal TA rotation. Only 32.1% of PDs saw a benefit of TA rotation for their residents’ education and less than half (46.9%) believed that it would be helpful to track ACGME case logs regarding their residents’ exposure to emergency surgery for life-threatening or multiorgan trauma. Practicing anesthesiologists: A majority of anesthesiologists (88.9%) recalled that their residency training occurred at a level 1 trauma center and 85% felt that they had sufficient exposure to the emergency surgery for life-threatening or multiorgan trauma. Forty one percent recalled that their residency program had focused training in TA and 78.2% believed that it was beneficial to have had such training in their current practice. Whereas only 43.1% of them felt that anesthesiologists employed at level 1 trauma centers should have dedicated training in trauma, and the majority (91.2%) felt that it was important to have the necessary skills and knowledge to perform anesthesia for life-threatening or multiorgan trauma in their current practice. Trauma Surgeons: Most of the surgeons practiced at level 1 (75.6%) and level 2 (20.6%) trauma centers. Ninety-eight percent of the surgeons believed that an anesthesiologist is an essential partner in a multidisciplinary trauma team. Ninety-six percent agreed that anesthesiologists should receive dedicated training for life-threatening or multiorgan trauma during their anesthesiology residency, but only 68.6% of them felt that anesthesiologists are adequately trained to manage these cases in their centers. The survey responders (total of 1.135) submitted 417 free-text comments. The most common topics were duration and kinds of trauma training provided in anesthesia residency, sufficiency of exposure to emergency surgery for life-threatening or multiorgan trauma, opinion on a benefit of trauma anesthesia rotation for anesthesiologist’s education and practice, and skills missing with anesthesiologists working in trauma centers. To present data more completely, we calculated the lower and upper limits of the 95% confidence interval. This, along with percentages, should help readers understand the strengths and weaknesses of the data. Since the responses did not contain a numerical range (eg, 1–5), we could not evaluate them based on a Likert scale. DISCUSSION We present the large spectrum of opinions appraising the current state of TA education during anesthesiology residency training, its challenges, and the need for this training among 4 groups of physicians—the key participants in the current US trauma care systems—anesthesiology residents, anesthesiology residency PDs, practicing anesthesiologists, and trauma surgeons. Our study was subject to several limitations; the main limitation is a low response rate in 2 surveyed groups (the anesthesia residents and practicing anesthesiologists). This low response rate was expected as the survey links had to be distributed to large target audiences (4652 US anesthesiology residents and 31, 389 anesthesiologists who were active members of anesthesiology state societies) via intermediaries (chief residents and state society presidents/secretaries). The cooperation of the intermediaries was unpredictable; therefore, the response rates in these 2 groups could not be accurately calculated. Additionally, there was potential for recall bias in the responses of the practicing anesthesiologists, as there was variability in the time since their graduation from residency. Most of the anesthesiologists surveyed (residents, practicing anesthesiologists, and PDs) confirmed being trained at level 1 trauma centers and felt they had adequate exposure to emergency surgery for life-threatening or multiorgan trauma during their training. However, less than half recalled being offered a formal TA rotation or curriculum. Interestingly, while residents and practicing anesthesiologists saw a benefit in having a dedicated rotation in TA, PDs did not. Although most of the residents, PDs, and practicing anesthesiologists agreed that, overall, level 1 trauma centers provide residents with sufficient exposure to a variety trauma cases, they also commented on several barriers to TA training including insufficient volume of penetrating trauma and the sporadic nature and unpredictable timing of trauma, making it interspersed throughout their training. Furthermore, a majority of practicing anesthesiologists felt they could apply principles of managing other complex cases requiring resuscitation of shock and coagulopathies to trauma management (eg, liver transplants, ruptured abdominal aortic aneurysm, and major cardiac and spine cases). We specifically queried the practicing anesthesiologists on benefits of a TA fellowship.5 The majority of them were critical toward the idea of this fellowship. They felt that creating another anesthesiology subspecialty would “not be feasible,” was “not practical,” was “too restrictive,” and “would create new barriers.” At the same time, some responders saw the value of employing fellowship-trained faculty to provide high-quality TA education. Members of the ASA COTEP believe that providing the anesthesiology residents with structured training by a well-designed TA rotation with a focused curriculum is the best method to educate and prepare them for taking care of trauma patients. To address this concern, COTEP developed a model TA curriculum, which identified the ACGME core competencies and outlined the goals and objectives for junior residents (categorical anesthesia CA-1 and -2) and another for senior residents.6–8 Many anesthesiologists surveyed favored the implementation of required documentation of high trauma caseload during residency and competency training for trauma anesthesiologists to practice at a level 1 trauma center. However, the latest version of the ACGME resident case logs no longer lists trauma as one of the data entry items. More than half of the surveyed PDs felt that trauma cases should not be tracked in the ACGME resident case logs. The reasons provided by PDs for not tracking trauma cases included insufficient case numbers and confusion with the definition of “trauma cases.” Additionally, PDs believed that the ACGME case log is already tracking life-threatening pathology, providing experiences similar to trauma (eg, liver transplant, emergency major vascular surgery, and obstetric hemorrhagic complications), which require massive transfusion. Nevertheless, to ensure the success of a TA education, COTEP strongly believes that the number of trauma cases should be documented and the definition of trauma cases should be classified as “life-threatening or multiple-organ trauma.” Without these data, it would be impossible to assess the residents’ trauma experience. Although there are conflicting views among anesthesiologists, residents, and PDs with respect to TA education and training, both COTEP members and trauma surgeons share the belief that a dedicated TA curriculum is warranted and needed. The vast majority of surgeons believe in required TA education for those anesthesiologists providing care to trauma patients at level 1 trauma centers. However, less than half of the anesthesiologists saw the need for this training. Many of the anesthesiologists believed that the TA skills “could be learned on the job” and that a practicing anesthesiologist “should be able to get up to speed with focused additional training, such as continued medical education (CME).” Moreover, the trauma surgeons emphasized the importance of the rotation on trauma and critical care service for anesthesiologists providing care for trauma patients. They felt this rotation should take longer than what is currently offered at anesthesiology training programs and include 3 months of intensive care unit training during CA-3 year. The surgeons also stressed the value of both high-fidelity (mannequin-based) and low-fidelity simulation (case discussion) training. Additional skills suggested to be incorporated into training included fostering leadership and team-building skills in trauma patient resuscitation. Both anesthesiologists and trauma surgeons agreed on the importance of the Advanced Trauma Life Support course, interdisciplinary conferences (including morbidity and mortality) with the anesthesiology, surgical, and emergency medicine departments, and hands-on practice sessions to master techniques (eg, cricothyrotomy, intraosseous line placement). There is a concerning disconnect between the trauma surgeons and the anesthesiologists around the latter’s knowledge and skill level to manage patients with life-threatening or multiorgan trauma. While 91% of practicing anesthesiologists believed that they had the necessary skill level, only 69% of the trauma surgeons felt that the anesthesiologists at their institutions had been adequately trained to manage these types of cases. Of the 450 trauma surgeons who responded to the survey, 135 (30%) reported skills that were deficient in anesthesiologists providing trauma care, including poor teamwork and coordination of care, as illustrated by the representative statement: “anesthesiologists need to be daily members of the trauma team, not every once in a while”; reluctance in responding to trauma alerts; an inability to expedite access for emergent procedures and to coordinate aggressive trauma resuscitation; the overuse of nurse anesthetists; and lack of communication with the surgeon regarding hemodynamics during intraoperative resuscitation were also concerns expressed by the surgeons. Trauma surgeons felt anesthesiologists lacked understanding of modern concepts of shock and trauma and evidence-based resuscitation strategies, such as damage control resuscitation, permissive hypotension, and hemostatic resuscitation.9,10 They felt that in general, anesthesiologists were slow to implement massive transfusion protocols and goal-directed management of acute traumatic coagulopathy based on viscoelastic methods, such as thromboelastography and rotational thromboelastometry.11 This is in agreement with data that anesthesiologists have gathered from their own practices.12 The surgeons also felt that anesthesiologists have not been adequately trained in intravascular volume assessment, minimizing the use of crystalloid solutions and avoiding the use of colloids in trauma scenarios. Other comments included statements such as, “anesthesiologists fail to recognize that ‘normal’ hemoglobin in an actively hemorrhaging patient is meaningless”; “unwilling to transfuse blood based on abnormal base deficit”; “use pressers without communication with surgeon.” Other respondents suggested more focused education on resuscitative endovascular balloon occlusion of the aorta, emergency thoracotomy, and emergency cricothyrotomy. A very critical point made by the trauma surgeons was that anesthesiologists may treat trauma patients just like elective patients with hemorrhage and hemodynamic instability. They made concerning comments regarding the common assumption apparently made by anesthesiologists that trauma required the same resuscitation as open heart, liver transplant, aortic surgery, and other cases with intraoperative hemorrhage, believing themselves to be equipped to care for trauma patients “because they deal with sick patients every day,” without any specific knowledge of current concepts in trauma resuscitation. Therefore, although most of the residency program training is performed at level 1 trauma hospitals and most surveyed anesthesiologists do not perceive a benefit in focused TA education, trauma surgeons disagreed. Trauma surgeons felt that practicing anesthesiologists lacked the knowledge and skills to appropriately manage trauma patients. These beliefs are shared by the authors and members of ASA COTEP, who realize the value of and support the implementation of a TA curriculum. CONCLUSIONS Our survey results revealed that a majority of anesthesiology residency programs conduct their training at the level 1 trauma hospitals, which ensures an adequate exposure of their residents to emergency surgery for life-threatening or multiorgan trauma. However, less than half of the programs that responded to our survey augment the exposure with a regimented education, such as didactic curriculum or formal rotation in TA. Furthermore, most of the residency PDs do not see the benefits of such education, unlike their current trainees and graduated anesthesiologists in various stages of their practice. Such a disconnect and a lack of formal education in TA could explain serious gaps in knowledge of unique physiology of shock and trauma and in understanding the principles of resuscitation. These deficiencies were stressed in numerous comments of the trauma surgeons, the largest group of responders and with one of the highest response rates. Our survey revealed substantial differences in perception of abilities of the anesthesiologists employed by the level 1 trauma centers—while practicing anesthesiologists were confident they were more than adequately trained to provide anesthesia to the trauma patients, the surgeons felt that they were inept to do this job. Thus, the vast majority of trauma surgeons supported the need of dedicated training in anesthesiology for life-threatening or multiorgan trauma during anesthesiology residency. These concerns raised by trauma surgeons highlight the premise that perhaps our current TA training is inadequate and support the COTEP’s viewpoint that implementing a dedicated TA curriculum in all anesthesiology training programs would be a stepping stone toward improving the knowledge and skill sets needed to care for trauma patients. TA is not just a mere practice of massive blood transfusion and coagulation management, but it requires a certain aptitude and mastery to efficiently deliver safe and effective multidisciplinary acute and trauma care in and out of the operating room environment, as well as national and international disaster preparedness. Dedicated training will give the authority to anesthesiologists to become academic and administrative leaders in an ever-growing acute and trauma care specialty. DISCLOSURES Name: Olga Kaslow, MD, PhD. Contribution: This author helped design and conduct the study, analyze the data, and prepare the manuscript. Dr Kaslow has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files. Conflicts of Interest: None. Name: Catherine M. Kuza, MD. Contribution: This author helped design and conduct the study, analyze the data, and prepare the manuscript. Conflicts of Interest: None. Name: Maureen McCunn, MD, MIPP, FCCM. Contribution: This author helped design and conduct the study, analyze the data, and prepare the manuscript. Conflicts of Interest: None. Name: Armagan Dagal, MD, FRCA. Contribution: This author helped design and conduct the study, analyze the data, and prepare the manuscript. Conflicts of Interest: None. Name: Carin A. Hagberg, MD. Contribution: This author helped design and conduct the study, analyze the data, and prepare the manuscript. Conflicts of Interest: Dr Carin A. Hagberg has a financial relationship with Ambu, Cadence Pharmaceuticals, Karl Storz Endoscopy, and MedCom Flow in the form of funded research and is an unpaid consultant for Ambu, Covidien, and SonarMed. Name: Joseph H. McIsaac, III, MD, MS. Contribution: This author helped design and conduct the study, analyze the data, and prepare the manuscript. Conflicts of Interest: None. Name: Venkat R. Mangunta, MD. Contribution: This author helped design and conduct the study, analyze the data, and prepare the manuscript. Conflicts of Interest: None. Name: Richard D. Urman, MD, MBA. Contribution: This author helped analyze the data and prepare the manuscript. Conflicts of Interest: None. Name: Chris A. Fox, PhD. Contribution: This author helped design and conduct the study, analyze the data, and prepare the manuscript. Conflicts of Interest: None. Name: Albert J. Varon, MD, MHPE, FCCM. Contribution: This author helped design and conduct the study, analyze the data, and prepare the manuscript. Conflicts of Interest: None. This manuscript was handled by: Richard P. Dutton, MD.

Traditionally, in the German-speaking countries, trauma patients are treated by general surgeons specialized in trauma surgery known as the Unfallchirurg. Over the last decade, a trend towards a lower influence of surgeons and a higher influence of subspecialties in the emergency department has been noted. With additional transformations in the health care system towards highly specialized medicine and the arising of new (sub-) specialties, diversification in the management of the trauma patient appears to occur. The new curricula for surgical disciplines providing trauma care will widen this issue even further, moreover, triggered by the Anglo-American medical model. The primary aim of this study was to evaluate the current situation in German-speaking countries concerning the management of trauma patients. The interfaces between emergency physicians, orthopaedic and general surgeons have been investigated concerning the management of the trauma patients. Additionally, different future scenarios have been evaluated. An online questionnaire was submitted to members of the German Society of Trauma and Orthopaedic Surgery [Deutsche Gesellschaft für Orthopädie und Unfallchirurgie (DGOU)], including both general and orthopaedic surgeons, emergency physicians and also some members from Austria, the Netherlands and Switzerland. Questions dealt with demographic data, the current situation in the clinic of the responders in terms of management of mono- and polytrauma patients as well as fracture care. In addition, various future scenarios were evaluated. 293 members of the DGOU answered the questionnaire. The majority of the responders (45%) were orthopaedic surgeons and 34% were general trauma surgeons. Sixty-two per cent of hospitals run their emergency departments with emergency physicians. Treatment of both mono- and polytrauma patients in the emergency department is equally distributed between general and orthopaedic surgeons. Fracture care, however, is predominantly (65%) being performed by general trauma surgeons in both mono- and polytrauma patients. The majority of the respondents (80%) do not want to change the current situation and predict that in the future fracture care will still be performed by general surgeons' specialized in trauma surgery. Approximately two-thirds of the responders do not believe that emergency physicians will play a bigger role in the management of trauma patients in the future. Despite the growing importance of emergency physicians, separated in the emergency room between surgical and internal medicine fields, in the acute care of surgical patients in the emergency departments, their role in the management of the polytraumatized patients remains limited. More than 13years after the new curricula for orthopaedic and general surgery have been implemented in Germany, fracture care is still predominantly provided by general surgeons specialized in trauma surgery. In conclusion, it seems that the general surgeon specialized in trauma surgery still plays and wants to play the key role in the management of the polytrauma patient and fracture care in German-speaking countries.

Background: In the emergency department (ED), pain is the most common complaint, especially among trauma patients. However, two-thirds of trauma patients are discharged from EDs with moderate to severe pain. Therefore, pain management is an important part of care in trauma patients. Objective: To assess the effectiveness of pain management among trauma patients in the ED. Method: This is a retrospective cohort study conducted on adult trauma patients who attended the ED in King Abdulaziz medical city (KAMC) in Jeddah from June 2016 to July 2018. The study evaluated if the pain was evaluated during the patient encounters, and the pain score was registered. Furthermore, we assessed if pain medications were administered, their type and dosage, and the pain score evaluation before and after administration. Pain score was scored using the numeric pain scale. Data were collected from the health information system (Best care®) and analyzed using SPSS version 24. Results: Initial pain assessment occurred only in 69% of our population, while assessment after medication administration happened in 71% of patients. The median between the time of arrival and the time of Initial Assessment was 19 minutes. The Mean difference between pain scores before and after pain management was one on a numeric pain scale with a P-Value of 0.001. 36.7% of Patients received appropriate medication based on their pain score improvement result. Opioid was used as an initial pain management drug in 35% of patients. Conclusion: There is a big room for improvement in pain management in trauma patients in emergency departments. Emergency care providers should observe the timeliness and appropriateness of pain management. Evaluation and re-evaluation of pain before and after pain medications or other pain-relieving intervention needs to be more frequent and efficient. [SJEMed 2021; 2(3.000): 257-261]