Year : 2016 | Volume
: 1 | Issue : 1 | Page : 1--2
Cardiac and Thoracic Effects Following Trauma: Foreword with Perspective and Philosophical Reflections
Kenneth L Mattox
Distinguished Service Professor, Division of Cardiothoracic Surgery, Baylor College of Medicine; Department of Surgery, Chief of Staff and Surgeon-in-Chief, Ben Taub Hospital, Houston, Texas, USA
Kenneth L Mattox
Distinguished Service Professor, Division of Cardiothoracic Surgery, Baylor College of Medicine; Department of Surgery, Chief of Staff and Surgeon-in-Chief, Ben Taub Hospital, Houston, Texas
|How to cite this article:|
Mattox KL. Cardiac and Thoracic Effects Following Trauma: Foreword with Perspective and Philosophical Reflections.J Cardiothorac Trauma 2016;1:1-2
|How to cite this URL:|
Mattox KL. Cardiac and Thoracic Effects Following Trauma: Foreword with Perspective and Philosophical Reflections. J Cardiothorac Trauma [serial online] 2016 [cited 2018 Mar 20 ];1:1-2
Available from: http://www.jctt.org/text.asp?2016/1/1/1/194037
What an absolute honor to be given the opportunity to write an early editorial perspective for an early volume of any journal. This journal represents several areas which have been components of my entire professional career - trauma, cardiac, thoracic, critical care, emergency care, resuscitation, education, research, and now using a virtual environment (the internet) as a vehicle for bringing all of these together. Although labeled as an editorial, this manuscript is in actuality a foreword, an introductory perspective, a philosophical reflection of my views on surgery, on trauma, and on the current evolutions which are happening to surgical education, surgical health-care delivery, surgical financing, surgical research, and the building of a surgery leader for the future. Thank you, Dr. Moheb Rashid for giving me this unique position and opportunity.
Progress is made by visionary leaders who have the courage to fail. Certainly, Dr. (Editor) Moheb Rashid recognizes that to be an editor of a NEW journal, a new INTERNATIONAL journal, a new international VIRTUAL journal, and a new international virtual SURGICAL AND TRAUMA journal opens more options for failure to fail than one can ever imagine. It is the visionary adventurer who braves the opposition, the deadlines, the proofreading, and the frustrations of corralling an international editorial board to regularly produce a product about which now the entire world has the instantaneous opening to find fault and disagreement.
Such a journal is in keeping with the disappearing world of printed books and journals being only in the historic sections of libraries. Libraries are becoming banks of computers with access to appropriate electronic sources of controlled and peer-reviewed learning material. Every student knows the value of an instantaneously available search engine on all of the many ready communication devices to provide a 30 s sound bite answer to any and all questions from their teacher. Now all such communication devices come complete with the suffix, "smart" to indicate whatever, to indicate that the device serves as a peripheral "brain." What this technology does offer to editors and publishers of medical journals is an almost immediate submission, peer review, and electronic cyber publication. I am aware of these three steps occurring with a special edition medical journal in <3 days. I well remember in decades past, receiving a mail packet containing the manuscript, sending the scored report back to the editor, and then later receiving a revised manuscript to reevaluate. The manuscript preparation, revision, corrections, repreparation, submission, processing, mailing, review, report of the review, reprocessing, submission of the final-approved, peer-reviewed manuscript to the publisher, publication of the printed journal, mailing, and finally arrival at offices for reading; the entire process could take anywhere from 3 to 9 months or even more. What a difference the computer and internet age has made in our ability to almost instantaneously affect this process.
What is "Trauma?" In the second century BC, a Greek legal document, crudely written on a shard, uses a word to describe a wound and is spelled in the letters, t r a u m a. This word then has been used to describe various conditions ever since. Until the mid-1970s, the word "trauma" was more widely perceived as being a mental or event, than producing an impression on the brain of a physical injury. It was principally efforts of the American College of Surgeons, Committee on Trauma, during the 1970s and 1980s that the word "trauma" was widely marketed to be used in trauma centers, trauma registry, trauma surgeons, trauma networks, trauma fellowships, and trauma journals. Trauma is now increasingly associated with physical injury.
Especially in the chest, the etiology of the trauma has an impact on a specific injury pattern, the workup required, the planned therapeutic intervention, and the potential outcomes. This variance is more important for a clinician to comprehend and differentiate than any other region of the body. Tragically, even seasoned general trauma surgeons often still view cardiothoracic injuries as a mystery and not infrequently apply inappropriate diagnostic tests and therapeutic interventions. As an example, 25% of tube thoracotomies in any hospital have some incorrect variance somewhere in the indication, placement, or mechanics of the chest tube circuit. The impact of edged instruments, penetrating projectiles, blunt force to the chest wall, iatrogenic penetration of a thoracic organ, physiologic changes to injury to an area distant to the thoracic cavity, and other etiologies all have different patterns. Although not difficult to differentiate, the physician evaluating or treating (or even transferring) a patient with such an injury has a responsibility to integrate the anatomy, the physiology, the patterns of injury, and the course of postinjury effects, if one is to expect the maximum opportunity for recovery.
Huge differences exist among the different health-care workers, including physicians in the interface with disease and treatment. Increasingly, physicians, including surgeons, are focusing their practices on single organs, such as breast disease or diseases of the liver, or in single areas of interest, such as surgical oncology or colon and rectal disease, or pediatric psychiatry. Life and literature review becomes extremely simple, and one might even add a potential for being boring, with such increasingly narrowed focus. Euphemistically, such surgeons are whispered to be "single organ surgeons" or SOS for short. The surgeon who assumes the responsibility to care for the trauma patient leads one of the most diverse and exciting of lives of any surgeon in the health-care community. The requirements to know a broad scope of information, understand the entire extent of human anatomy, knowing the literature of multiple disciplines outside of the trauma and acute care surgery literature, and integrating all of these diverse sources of data make the trauma surgeon and especially the surgeon with focus on cardiothoracic trauma, to be at the very pinnacle of the health-care pyramid pecking order. This "go-to" surgeon of any community has a sense of pride that they are referred the most challenging of cases, see patients at the nadir of their upset physiologic equilibrium, and are expected to recognize and reverse the most complex of problems encountered in medicine. Dealing with the complexities of bariatric surgery, transplantation, elective cardiovascular surgery, or even forensic psychiatry is minor as compared to the four-dimensional Rubric Cube set of problems of cardiothoracic trauma. Even the seasoned general trauma surgeons, who work in the abdomen, extremity blood vessels, and burns, often are very afraid of and shy away from acute thoracic injury. For the surgeon who is comfortable in climbing to that pinnacle of health-care challenges, it is in the arena of cardiothoracic trauma that he/she finds peace and contentment as well as satisfaction of being able to handle medical problems which bring fear and retreat to the physician seeking an easy compromise and soft well-paying day job.
Regardless of where trauma happens in the body, chest complications are possible. The list of such complications is very long and ranges from infectious, metabolic, embolic, and many others. A focus on this constellation of complications could be a subject of a book or journal of its own. Among these complications, the definition and understanding and even treatment protocols for such complications varies greatly among medical disciplines, perhaps being best understood by thoracic surgeons with an interest in trauma. A prime example is the 2016 confusion regarding venous thrombosis and inflation and subsequent findings of pulmonary insufficiency thought to possibly be related to the venous pathology. With use of computed tomography scanning of pulmonary artery and arteriole clot, and with the ICD-9 and ICD-10 diagnostic codes being identical for large central obviously embolic venous clot being identical to the small peripheral low-flow, soft tiny thrombi, it is natural that misunderstanding would be rampant in the literature. A new journal will naturally focus on such turf differences. Complications due to fluid choices and crystalloid overloading are legend, especially secondary to differences in protocol for the trauma patient in the field (EMS), emergency department, anesthesia and the operating room, and in the Intensive Care Unit.
Traditionally, not only was chest injury poorly understood by the nonthoracic surgeon, there was an element of mystery in many general surgery textbooks or even trauma textbooks written by general surgeons. Textbooks regarding trauma written by nonsurgeons contained chapters on thoracic trauma and thoracic complications of trauma in general, which were often not only misleading but also contained material which was incorrect. Many of the chest trauma protocols, such as needle decompression of the chest, pericardiocentesis for acute hemopericardium, indications for thoracotomy, choices of incisions, and positions, are dated and possibly incorrect. The prudent reader of this journal will be directed to new and exciting evidence-based publications.
It would be tempting to talk in this editorial about all of the regions of the chest where trauma could and should be written about: chest wall injuries, direct injury to the heart, lung injury, mediastinal issues, and transition zones, but I will leave that detail to the editor and section editors.
Every cardiothoracic surgeon, and every surgeon, regardless of subdiscipline who cares for trauma patients should look forward to receiving, reading, and participating in contributing to this journal. It will be a source for new information as well as international collaborative information exchange as well as research in many areas. I would anticipate that the editor would create a section regarding controversy and regularly stimulate the international participants.
This new journal is an exciting addition to our reading enjoyment. I congratulate the editor and the visionaries who have organized and developed this journal. And I look forward to seeing many contributions from its international readership.