Trauma fellowship for emergency physicians: a necessity or demand?

Abstract

Due to the concerning rate of motor vehicle collisions and consequent significant morbidity and mortality in Iran, higher-quality trauma care than currently available is needed. These alarming statistics argue for establishing trauma-specific diagnostic and treatment protocols and presence of a dedicated trauma team.
It has been well documented that the presence of a trauma team has led to significant improvement in trauma care. The trauma team leadership is a “model of practice” of specifically trained team leaders in the emergency department (ED). The timely presence, interpersonal communication, and leadership capabilities of trauma team leaders (TTLs) improve team performance, time to diagnostic imaging, and faster transfer to hemorrhage control.

In this regard, the largest retrospective study which assessed TTL implementation, included 20,193 patients with injury severity score (ISS) ≥12 from 3 Canadian Level-1 trauma centers from 2003 to 2017. They concluded that TTL implementation did not lead to admission delays from the ED. In addition, several studies addressed the efficacy and performance of different disciplines as TTLs. In a study performed by Taylor et al. on 12,961 major trauma adults presenting to trauma bays during trauma activations, data was recruited from provincial trauma registries at six level 1 trauma centers across Canada over 10 years. They assessed risk-adjusted in-hospital mortality for trauma patients receiving initial care from surgeons versus non-surgeon TTLs and concluded comparable outcomes among varying specialties. Although this study was underpowered to assess the outcome in the sickest and most unstable patients.
In this context, a systematic review and meta-analysis of observational studies reported similar results assessing survival, missed injuries, and length of stay. They suggested the fact that resuscitation in the trauma bay can be effectively and timely performed by TTLs other than surgeons.
Various specialist registrars who have completed local trauma team leader (TTL) development programs played the team leadership role including surgeons, emergency department (ED) consultants, intensivists, and anesthesiologists according to previous studies in North America and Europe.
Thus, trauma fellowship for emergency physicians has been known for years in developed countries and graduated trainees improve the level of care for non-accidental and accidental injuries including mass casualty incidents. Today, despite the overwhelming situation of injured patients in EDs in Iran, only general surgeons have the chance to be trained in this fellowship, while most of them are involved in the operating rooms and cannot play role as the first line physicians to visit critically ill trauma patients. Therefore, there is no specialized and determined trained service in the EDs to take care of this major group of patients all over the country whereas the worldwide trend now is toward trauma care optimization.
Since time is key in trauma management, there is an increasing necessity to change policies to decrease the present high mortality rate and to improve multidisciplinary care, specifically designed with the critical role of trauma team leaders in the EDs.
On the other hand, the development of emergency medicine (EM) fellowships and subspecialties will shed light on the desire for continuing education among this specialty graduates in Iran. The safety of workplace, appropriate payments, and support for physicians’ rights by authorities and insurances are also determinants and necessities that result of and lead to the successful implementation of emergency medicine fellowships and its success in Iran.