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Invited Critique |

Surgeon- and System-Based Influences on Trauma Mortality—Invited Critique

David V. Feliciano, MD
Arch Surg. 2009;144(8):764-765. doi:10.1001/archsurg.2009.93.
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Haut et al are to be congratulated for a comprehensive analysis of the changes that occurred in their trauma center after the introduction of new leadership and structure in 1998. The experience of the in-house trauma attending surgeon did not have an effect on overall patient mortality, whereas the change in leadership and structure decreased mortality when novice surgeons were the caregivers. The use of mortality as an end point in analyzing trauma care does have some limitations. For example, it would be helpful to know the actual percentages of blunt vs gunshot wound vs stab wound mechanisms of injury in all groups. Patients with hypotension in the former 2 groups have significant mortality compared with the latter group when the admission base deficit exceeds −15. It would be expected that the greatest advantage of having an experienced surgeon available would be in the performance of index abdominal trauma operations, that is, those involving repair of complex injuries to the liver, pancreaticoduodenal complex, and major abdominal vascular structures. The ISS simply does not differentiate between magnitudes of abdominal injuries in patients with penetrating trauma. In addition, no information is given about the number of preventable or potentially preventable deaths when comparing novice surgeons with the senior surgeon. If 10% to 15% of the deaths in the patients cared for by novice surgeons were in these categories compared with 1% to 2% for the senior surgeon, the entire analysis using mortality as an end point would be in question.

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