More surgeons, less trauma

EDITORIAL

More surgeons, less trauma

Gustavo Pereira Fraga^I; Francisco Salles Collet-Silva^II; Hamilton Petry de Souza^III

^ITCBC-SP, FACS. University of Campinas, São Paulo, Brazil

^IITCBC-SP, FACS. University of São Paulo, São Paulo, Brazil

^IIITCBC-RS, FACS. Pontifical Catholic University of Rio Grande do Sul (PUC-RS), Porto Alegre, Brazil

Brazil currently lives in a time of great unrest and dissatisfaction; many have taken to the streets demanding improvements in areas such as transportation, education, health and especially against corruption. The federal government responded by attributing the main cause of the health problem as being the chronic deficit of physicians in the National Health System (Sistema Unico de Saude - SUS) and an immediate solution was the publication of an Act in the form of a "More Physicians" program and, if necessary, the importation of doctors from abroad¹. The problem is complex and impossible to be resolved with authoritarian measures without the active participation of the medical entities and higher education institutions, but at least it is serving as a milestone towards the mobilization of professionals looking for better solutions to ensure the survival of a little-funded national health system. And we, Brazilian surgeons, need to actively participate in the adoption of this new phase of the health system in Brazil.

Medical demographic data show that Brazil has 1.8 doctors per 1,000 inhabitants and that there are 13,609 general surgeons operating in the country². In parallel to the discussions about the reorganization of the medical residency programs in general surgery, there is a need to train more surgeons, since this is one of the specialties included in Pro-Residence³. We also have a mission to improve the teaching of dealing with trauma during degree programs in all areas of health. In addition to more surgeons, there is a need to train more trauma surgery professionals. This justifies the increasing integration between the Brazilian College of Surgeons (CBC) and the Brazilian Trauma Society (SBAIT), something that has been occurring in recent years, but which needs to be intensified, especially with regards to the training of human resources for the public health system.

We understand that training more surgeons to work in emergency rooms would lead to a lower incidence of trauma and a reduction in morbidity and mortality, since in trauma systems in developed countries these professionals are employed by major medical centers, which cover all phases of trauma care, including prevention. It would be utopian to think that this measure alone would minimize the epidemic of deaths from homicide, accidents and other forms of trauma, but it is proven that a well-organized systems, including surgeons adequately prepared in medical residency, reduce preventable deaths and sequelae in the trauma patients. Brazil is one of the only countries in the world that bestows the title of Surgeon General on a doctor after only two years of residence. Another thing: during one more year of practice in Trauma Surgery, it is not possible to train a professional to understand epidemiology, prevention and pre-hospital care, to be competent in diagnosis and management (surgical or nonoperative) in the emergency room, to lead other professionals and medical specialties that severe trauma demands, to develop surgical techniques for complex cases, to practice in surgical intensive care units, to register and monitor the quality of care provided, to assist in the rehabilitation of victims, to develop research, and develop other skills required during this training phase. That is to say, this is the training for a trauma and emergency surgeon, as obviously this would be the same surgeon responsible for non-traumatic surgical emergencies in the emergency rooms of large hospitals, because this is what the SUS and the Brazilian population need, to face the third major cause of death in the country.

SBAIT has done its part. It actively participated in the drafting of the Trauma Care Line⁴ together with the Ministry of Health and other medical societies, it is developing the Brazilian Trauma Registry, it has organized prevention projects (Prevent Alcohol and Risk-Related Trauma in Youth - PARTY, for example)⁵, it has been conducting courses and symposia in different states, it holds frequent meetings via telemedicine, it assists in the opening of residency programs in trauma surgery, it has opened new chapters and is attracting more members, many of whom are graduates of trauma leagues. We need to do and train more.

From a scientific standpoint, the partnership with CBC has been very important. It began in 2008, when the XXI Panamerican Trauma Congress, together with the VIII SBAIT Congress and the X Brazilian Congress of Trauma Leagues (CoLT) were held in Campinas, and a supplement of the CBC Journal was published with abstracts from 347 papers⁶. In 2011 a study showed that only 2.9% of these papers were published in full after two years⁷. In 2012 the project "Evidence-Based Telemedicine - Trauma & Acute Care Surgery " (EBT-TACS or TBE-CITE) was started with support from the University of Toronto, in which each issue contains recommendations to Brazilian surgeons following discussions between different services⁸. In August 2012, during the World Trauma Congress, X SBAIT Congress and XIV CoLT, the CBC journal devoted its 4^th issue to papers of trauma and emergency surgery, with a selection of 13 original articles which were published in full and presented at the congress.

A recent study showed that the production of scientific papers in trauma and emergency surgery in Brazil has been increasing in recent years⁹. Due to the actions of SBAIT and CBC, this increase continues with issue 4 of volume 40 of the CBC journal, and the trend is that the growth will accelerate, since there are many incentives for young surgeons to publish their studies, disseminating knowledge and research.

In the current issue, international readers can become familiar with studies carried out by Medical School Graduates and their advisors on accidents involving biological material and subsequent guidance on discharge from the emergency room. It also contains original articles on prehospital care, trauma in the elderly, head trauma by projectiles from firearms, predictive factors of severe abdominal injuries in blunt abdominal trauma, the evolution of nonoperative treatment (in liver, spleen and kidney injuries) and the use of negative pressure therapy in complex perineal trauma. The journal features an article on nontraumatic abdominal emergencies, including a report on experience with gallstone ileus, and also an excellent review article on nutrition in trauma.

In this troubled national scenario, in which the deficiency of the health system has been attributed to the lack of physicians, we believe that SBAIT and CBC should continue working together, committed to training more surgeons, but with quality, to residency programs with a greater training period, encouraging assistance from the national health system, teaching and research. If we pass all this to the new generation of surgeons, involving them in prevention, maybe it will be possible to achieve another goal in the future - to have fewer traumas decimating the Brazilian population.

REFERENCES

• ¹
  Presidência da República.( Casa Civil.( Subchefia para Assuntos Jurídicos. Brasil. Medida Provisória No 621, de 8 de julho de 2013. Institui o Programa Mais Médicos e dá outras providências. Disponível em http://www.planalto.gov.br/ccivil_03/_Ato2011-2014/2013/Mpv/mpv621.htm Acesso em 9 de agosto de 2013.
• 2. Scheffer M, Biancarelli A, Cassenote A. Demografia Médica no Brasil: dados gerais e descrições de desigualdades. São Paulo: Conselho Regional de Medicina do Estado de São Paulo e Conselho Federal de Medicina, 2011.
• ³
  Ministério da Saúde. Brasil. Programa Nacional de Apoio à Formação de Médicos Especialistas em Áreas Estratégicas (Pró-Residência). Edital No 29, de 27 de junho de 2013. Disponível em http://sigresidencias.saude.gov.br/ Acesso em 9 de agosto de 2013.
• ⁴
  Portaria Nº 1.366, de 8 de julho de 2013. Estabelece a organização dos Centros de Trauma, estabelecimentos de saúde integrantes da Linha de Cuidado ao Trauma da Rede de Atenção às Urgências e Emergências (RUE) no âmbito do Sistema Único de Saúde (SUS). Disponível em http://www.brasilsus.com.br/legislacoes/legislacoes-recentes/legislacoes/gm/119738-1366.html Acesso em 9 de agosto de 2013.
• 5. Banfield JM, Gomez M, Kiss A, Redelmeier DA, Brenneman F. Effectiveness of the P.A.R.T.Y. (Prevent Alcohol and Risk-related Trauma in Youth) program in preventing traumatic injuries: a 10-year analysis. J Trauma. 2011;70(3):732-5.
• 6. Mantovani M, Fraga GP, Petry HS. Trauma Sem Fronteiras. Rev Col Bras Cir. 2008;35(Supl. 1):v.
• 7. de Andrade VA, Carpini S, Schwingel R, Calderan TR, Fraga GP. Publication of papers presented in a Brazilian Trauma Congress. Rev Col Bras Cir. 2011;38(3):172-6.
• 8. Fraga GP, Nascimento B Jr, Rizoli S. Evidence-based telemedicine: trauma & acute care surgery (EBT-TACS). Rev Col Bras Cir. 2012;39(1):3.
• 9. Fraga GP, Augusto de Andrade V, Schwingel R, Neto JP, Starling SV, Rizoli S. The scientific production in trauma of an emerging country. World J Emerg Surg. 2012 Aug 22;7 Suppl 1:S13.

Publication Dates

• Publication in this collection
  29 Oct 2013
• Date of issue
  Aug 2013