Emergency surgery over 111 years: are we still at a crossroads or ready for emergency surgery 2.0?
With 2015 at a close, it is now a solid 111 years that have passed since Halstead voiced his opinion in his 1904 address [1]. The statement still rings a very logical bell to everyone who either works in a hospital or ever was a patient. However, the action to ensure this has not been as logical and straightforward with each generation of surgeons having their own challenges to face. As I have addressed the topic before in this Journal [2, 3], and elsewhere [4, 5], it is with some reluctance (“do I need to address this topic again?”) yet still with a feel of need (“where are we now?”) that I take to the pen. First, and regrettably, emergency cases are still a neglected field in most countries, despite acknowledged high mortality numbers and increasing documentation of care issues [6–10]. The several explanations to the discrepancies between need and provision are many and include political, societal issues as well as those related to education and training. The changes seen in medicine, with a predominant “omics” focus and personalized medicine may not fit immediately with unpredictable, out-of-hours presentations for which resources are fewer and outcomes are worse. Let alone the vanishing training in general surgery, for the better good for highly complex surgery procedures that benefit from isolated focus, yet separates the “generalism” of the past from the narrow focus of the present. Together with restricted working-hours, it becomes apparent that the exposures in training are influenced. Notably, most of these changes are for the better good of patients, but the groups that lack organized interest groups, a patients advocacy organization and defined or named funding institutes will have to live off the crumbles left after supra-specialized fields have had their say. Alas, the decibel democracy may jeopardize the right to care for some patients, and this is enhanced when the proper specialist, specialty or department does not even have a name and address from where to voice their views. Thus, “emergency surgery” needs to be defined, given a name and a place in every organization structure lest it be neglected and served as a stepchild compared to its more ‘prominent’ siblings. Exactly how, what and where is less important (e.g. tailored to the institutions need and service), as long as it will have a name and place on the institution map. Second, as follows from the above, fight over resources and operating rooms needs a better organized approach to the patient presenting with an emergency condition in need of care [11]. Highly efficient systems are possible and well-documented [12], as are the effects of creating specialized units from several different parts of the world [9, 13–16]. There is ample evidence to show that ringfencing of elective surgery from emergency care, creates cost-efficient pathways for both patient groups, with reduced disturbances, less cancellations and speedier and more efficacious management. So why not do it? Third, it appears that the development of a “new” specialty is what is done to address the need for focused attention to emergency surgical conditions, as general surgery as we know it is vanishing. In Norway, it appears that a new specialty structure and remodelling of training will dismiss “general surgery” as a defined specialty overall, and incorporate trauma and acute surgery into the current specialty of gastrointestinal surgery. While this may be a logical step from the current training situation and a reasonable logic in terms of disease burden Correspondence: ksoreide@mac.com Department of Gastrointestinal Surgery, Stavanger University Hospital, P.O. Box 8100, N-4068 Stavanger, Norway Department of Clinical Medicine, University of Bergen, Bergen, Norway