NOVEMER 2008 Volume 93, Number 11

FEATURES Stephen J. Regnier Editor Fahad’s journey 8 Linn Meyer Sylvia D. Campbell, MD, FACS Director of ACS Practice Patterns Survey, Part II: Communications Prescribing habits among surgical specialties 11 Karen Stein Charles M. Balch, MD, FACS; and Thomas R. Russell, MD, FACS Associate Editor Into the theater: Perspectives from a civilian trauma surgeon’s Diane S. Schneidman visit to the Combat Support Hospital in Balad, Iraq 16 Contributing Editor M. Margaret Knudson, MD, FACS Tina Woelke 2008 state legislative activity 26 Graphic Design Specialist Melinda Baker Alden H. Harken, MD, FACS Charles D. Mabry, DEPARTMENTS MD, FACS Jack W. McAninch, MD, FACS From my perspective 4 Editorial Advisors Editorial by Thomas R. Russell, MD, FACS, ACS Executive Director Tina Woelke Dateline: Washington 7 Front cover design Division of Advocacy and Health Policy

Socioeconomic tips 31 Future meetings ACS Coding Hotline: Cholecystectomy questions Linda Barney, MD, FACS; Albert Bothe, Jr., MD, FACS; Clinical Congress and Debra Mariani, CPC 2009 Chicago, IL, October 11-15 2010 Washington, DC, October 3-7 2011 San Francisco, CA, October 23-27

Letters to the Editor should be sent with the writer’s name, address, e-mail ad- dress, and daytime tele- phone number via e-mail to [email protected], or via mail to Stephen J. Regnier, Editor, Bulletin, American College of Surgeons, 633 N. Saint Clair St., Chicago, IL 60611. Letters may be edited for length or On the cover: A Ugandan mother’s plea on behalf of her son, who suffered from clarity. Permission to publish letters is assumed unless the a heart complication, inspired dedicated surgeons and nonsurgeons in Tampa, author indicates otherwise. FL, to coordinate stateside care for the child (see article, page 8). NEWS Bulletin of the American College of Surgeons (ISSN 0002-8045) is published Dr. Cameron installed as 89th ACS President monthly by the American Col- 33 lege of Surgeons, 633 N. Saint Honorary Fellowships presented to five prominent surgeons 34 Clair St., Chicago, IL 60611. It is distributed without charge Citation for Prof. Jacques Brotchi 35 to Fellows, Associate Fellows, Fernando G. Diaz, MD, PhD Resident and Medical Student Members, Affiliate Members, Citation for Prof. Joaquim Gama-Rodrigues 36 and to medical libraries and al- lied health personnel. Periodi- Carlos A. Pellegrini, MD, FACS cals postage paid at Chicago, IL, and additional mailing Citation for Prof. Gerald C. O’Sullivan 37 offices. POSTMASTER: Send Tom R. DeMeester, MD, FACS address changes to Bulletin of the American College of Sur- Citation for Mr. Bernard Ribiero 38 geons, 633 N. Saint Clair St., George F. Sheldon, MD, FACS, FRCSEd(Hon), FRCSEng(Hon) Chicago, IL 60611-3211. Cana- dian Publications Mail Agree- Citation for Prof. Russell W. Strong 40 ment No. 40035010. Canada L. D. Britt, MD, FACS returns to: Station A, PO Box 54, Windsor, ON N9A 6J5. In memoriam: James C. Thompson, MD, FACS, 1928–2008 42 The American College of Marshall J. Orloff, MD, FACS Surgeons’ headquarters is located at 633 N. Saint Clair Germany Traveling Fellow selected for 2009 47 St., Chicago, IL 60611-3211; tel. 312/202-5000; toll-free: Dr. Eastman appointed to 800/621-4111; fax: 312/202- national injury prevention advisory board 47 5001; e-mail:postmaster@ facs.org; Web site: www.facs. Report of the 2008 American College of Surgeons org. Washington, DC, office is located at 1640 Wisconsin Japan Traveling Fellow 49 Ave., NW, Washington, DC Sam M. Wiseman, MD, FACS, FRCSC 20007; tel. 202/337-2701, fax 202/337-4271. A look at The Joint Commission: Unless specifically stated International focus on accreditation 55 otherwise, the opinions ex- pressed and statements made Trauma meetings calendar 55 in this publication reflect the authors’ personal observations ACOSOG news: “Such stuff as dreams are made on”: and do not imply endorsement Laparoscopic rectal cancer trial 56 by nor official policy of the David M. Ota, MD, FACS; and Heidi Nelson, MD, FACS American College of Surgeons. 2009 Oweida Scholarship availability announced 57 ©2008 by the American ® College of Surgeons, all rights NTDB data points: ATVs: “All-terrain victims” 59 reserved. Contents may not Richard J. Fantus, MD, FACS be reproduced, stored in a retrieval system, or transmit- ted in any form by any means without prior written permis- sion of the publisher. Library of Congress number 45-49454. Printed in the USA. The American College of Surgeons is dedicated to improving the care of the sur- Publications Agreement No. gical patient and to safeguarding standards of care in an optimal and ethical 1564382. practice environment.

From my perspective

arlier this year, the American College of Surgeons announced the establishment

of a new Health Policy and Research

EInstitute, which is currently based at the University of North Carolina (UNC), Cha- pel Hill. Already this institute is enhancing the College’s capacity for analyzing issues and de- ’’ veloping thoughtful position statements, and we anticipate that it will assist this organization in our efforts to become an increasingly prominent presence in the policymaking arena. Establishment of the ACS Initial steps Start-up of this important branch of the College Health Policy and Research is being led under the careful guidance of George F. Sheldon, MD, FACS, Zack D. Owens Distin- Institute presents an guished Professor of Surgery at UNC’s School of Medicine. Dr. Sheldon, a Past-President of the opportunity for the American College, was selected for this position through a national search process. He is receiving adminis- College of Surgeons to play trative assistance from Thomas J. Ricketts, PhD, deputy director of the UNC Cecil G. Sheps Center a true leadership role in for Health Policy Research. The Cecil G. Sheps Center for Health Policy the health policy arena. Research is an institute within the UNC that reports to the vice-chancellor and collaborates with the schools of medicine, dentistry, public ’’ health, nursing, and allied health. The center has 140 full-time time researchers, numerous our efforts much more quickly than if we had graduate students, and substantial existing grant attempted to build an entirely new program support from the Health Resources and Services from scratch. Administration, the Agency for Healthcare Re- search and Quality, and the National Institutes Exploratory projects under way of Health. For its first project, the ACS Health Policy and This collaboration with an existing health Research Institute is studying surgeon work- policy research center is a new model that allows force issues. More specifically, the researchers at a professional organization, such as the College, the institute are attempting to answer questions to collaborate with demographers, statisticians, about how many surgeons will be needed to en- survey experts, and other experts in health ser- sure patient access to care in the future, which vices research. The collaboration between the specialties need to attract more trainees, and American College of Surgeons and UNC also the causes of geographic disparities in access to ensures that the ACS Health Policy and Re- surgical care. Dr. Sheldon and his team at UNC search Institute has access to the resources and have already conducted considerable research knowledge necessary to cultivate a nationally regarding the impending surgical workforce respected think tank. Drs. Sheldon and Ricketts crisis and have started to generate ideas about are both highly regarded authorities on health how the federal government can help to ensure care issues, and the Sheps Center has a long and that surgeons are accessible to the patients who distinguished record in conducting health policy need their services. research. Basing the institute at UNC during its Based on the institute’s research, the Col- early stages of growth has allowed us to initiate lege has arrived at some of the suggestions we 

VOLUME 93, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS intend to offer to health policymakers to assist Strong, coordinated presence them in addressing the workforce issue. These Because the institute’s staff will be conducting recommendations include the following: (1) research and helping to write position statements encouraging a well-planned expansion of U.S. on issues affected by the federal government, the medical school graduates and residency train- program’s headquarters will ultimately relocate ing programs, (2) providing federal financial to the building that will house the College’s support for specialties with lengthy training new Washington Office, which is scheduled for requirements, (3) eliminating caps on the completion in 2010. Having the College’s advo- number of residents eligible for federal sup- cacy and institute staffs in the same location will port at each training institution, (4) expanding allow for the timely exchange of information and programs that give financial support to rural ensure that all of our policy-focused efforts are physicians to include surgical specialists, and well coordinated. (5) providing incentives for surgeons to take call Although the ACS Health Policy and Research in our nation’s trauma centers and emergency Institute will be headquartered in Washington, departments. the institute will maintain a relationship with We anticipate that the ACS Health Policy and UNC. The fact of the matter is that our Washing- Research Institute will continue to play an in- ton Office will not have nearly the same research strumental role in helping the College to develop capabilities or staff capacity as our collaboration specific, scholarly, well-conceived strategies that with the Sheps Center affords us. lawmakers can apply in reforming the nation’s Establishment of the ACS Health Policy and health care delivery system. For example, as Con- Research Institute presents an opportunity for gress and the Centers for Medicare & Medicaid the American College of Surgeons to play a true Services strive to create a value-based, patient- leadership role in the health policy arena. It will driven schematic, surgeons will face mounting enable us to serve as a trailblazer by contributing pressures to document the effectiveness and real and factual data upon which to base solu- efficiency of the work they do. The institute will tions to the problems that have beset our health be useful in generating data that can show what care system. surgeons are doing well and where there is room for improvement. Furthermore, the institute will serve as a think tank where clinical scholars can examine and discuss the complexities of surgical practice and create a vision for the future of our profession. Currently, the College’s Division of Research Thomas R. Russell, MD, FACS and Optimal Patient Care is benefiting from the assistance of three young research fellows, in- cluding a Robert Wood Johnson Clinical Scholar and two new Clinical Scholars in Residence (see related story on pages 93–94 of the July Bulle- etin). W anticipate that the ACS Health Policy and Research Institute also will provide bright, young people who are interested in legislative and regulatory issues with a fertile training ground for exploring fresh, innovative ideas about how we, as a profession and as a nation, can improve patient care through reasoned policy decisions. These programs for young thought leaders ensure that this organization serves as a true “college” If you have comments or suggestions about this or for surgeons and is not just another professional other issues, please send them to Dr. Russell at fmp@ association. facs.org. 

NOVEMBER 2008 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS

Dateline Washington prepared by the Division of Advocacy and Health Policy

On September 11, the House Ways and Means Health Subcommittee House starts held a hearing on Medicare’s physician payment system. Testimony looking at payment focused on changes Congress should consider next year in order to avert the cut of more than 20 percent in Medicare reimbursement reform options scheduled to take effect in 2010. Witnesses included two former ad- ministrators of the agency now known as the Centers for Medicare & Medicaid Services (CMS): Bruce Vladeck, PhD, and Gail Wilensky, PhD. Dr. Vladeck expressed support for reforms similar to those that the American College of Surgeons has proposed, which would replace the current sustainable growth rate (SGR) methodology with a reim- bursement formula composed of separate spending targets for specific types of services. This new payment structure would include a distinct category for major surgical procedures and, consequently, spare surgery from the across-the-board, blunt payment cuts caused by the SGR. Dr. Wilensky also expressed interest in this proposal. For more informa- tion regarding this hearing, go to http://waysandmeans.house.gov/hear- ings.asp?formmode=detail&hearing=645.

On August 29, the College submitted comments to CMS regarding the ACS comments proposed rule for the 2009 Medicare physician fee schedule. The letter on fee schedule addresses the following provisions of concern to surgeons: a require- ment that physicians who furnish diagnostic testing services enroll as independent diagnostic testing facilities, changes to the effective date for Medicare billing privileges for physicians, an incentive payment and shared savings program, and updates to the Physician Quality Reporting Initiative. In addition, the proposal calls for developing means to address potentially “misvalued” services. To view the College’s comments, go to http://www.facs.org/ahp/views/medicare2009.html.

The College submitted comments on September 2 regarding the out- ACS comments patient prospective payment system and ambulatory surgical center on OPPS/ASC (OPPS/ASC) proposed rule. In this letter to CMS, the College addresses the following issues: a plan to extend payment policies for hospital- proposed rule acquired conditions to outpatient settings, a proposal to add imaging efficiency measures using 2008 Medicare administrative claims data, and suggested changes to the list of covered surgical procedures designated as device intensive. To view this correspondence, go to http://www.facs. org/ahp/views/ambulatory.html.

A new CMS claim adjustment reason code (CARC #213) becomes ef- New code for fective January 1, 2009, for use in denying claims that are noncompliant noncompliance with the Stark self-referral law. This legislation prohibits physicians from referring Medicare patients needing certain designated health with Stark law services (DHS) to facilities in which the physicians or an immediate family member have a financial relationship. Penalties for violations of the law include denial of payment, refund of amounts collected for DHS payment, and civil monetary fines. CARC #213 is the first specific code to describe claims denials resulting from violation of the Stark law. For more information, go to http://www.cms.hhs.gov/transmittals/ downloads/R1578CP.pdf. 

NOVEMBER 2008 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS

found the following message one early surgeon, reviewed the information and agreed Imorning when I opened my e-mail: to take his case. Jeanne Hardin-Gres—a nurse anesthetist and Am a Ugandan mother of three boys, my last my good friend and mentor—and I were leaving born son who is only seven months old was two for Uganda in just three weeks to review and weeks ago diagnosed with a heart complication. discuss the development of a medical complex The doctors at Mulago Heart Institute say he has that was being planned for the village of Papoli. a hole between the two wall chambers of the heart Ideally, Fahad and his mother, Anne, would travel and on top of that one of the pulmonary arteries is back with us, if details could be worked out. so narrow that the amount of blood pumped to the I contacted a travel agent who, amazingly, was lungs is minimal thereby affecting his breathing. able to get seats for Fahad and his mother on It’s so unfortunate that the condition cannot be the same airline flight. My friend and minister, rectified here in Uganda. I thought of contacting Rev. John DeBevoise, at Palma Ceia Presbyte- you in case you can be of help to me so my request rian Church, was able to raise the funds for the to you is to kindly assist me where possible to save tickets for Fahad and Anne. A letter was then the life of my sweet baby. Any kind of assistance is sent to Anne from the Gift of Life program to highly appreciated. help with obtaining passports and visas for her and her son. And so began Fahad’s journey Fahad could barely eat, he could not sit up, and Fahad Bukenya had Tetralogy of Fallot. At five he did not smile, but he looked at people with months of age, he began to weaken and become enormous eyes that had great pain. Each breath less active. He contracted malaria at six months was an effort. His nail beds and lips were blue, of age and was seen in his local hospital, where and he already had clubbing of his fingers. The his murmur was heard. He was then referred to first time I saw him, on a dark street in Kampala, Kampala, the capital city of Uganda, where at the my heart broke and was rebuilt…and I knew we Mulago Heart Institute the diagnosis was made must make this journey. with an echocardiogram. His aortic override was Anne was told by the U.S. Embassy that the 40 percent, his parachlorophenylalanine was staff would need to talk to me before visas could 9 mm with confluent branch pulmonary arteries. be granted. So after a week in the bush, we trav- No atrial septic defect, patent ductus arteriosus, eled on Friday morning to the capital to meet or coarctation of the aorta was seen, and there with representatives at the Embassy. was no VOT obstruction. I was told at the front gate again and again I have had the privilege of working with that visas were not issued on Friday. I then Heidi Hess in Tampa, FL, who coordinates the met with a representative at the Embassy, and Gift of Life program here run by Rotary Inter- I was told there would be no problem obtaining national. It is a program to help children who the visas the next week. I told him, “You don’t are unable to have cardiac surgery in their own understand—we are leaving tonight. If this baby countries and has served so many with such great does not come with us, he will die. If he comes need. I knew that this baby must be helped, and with us, he will have his only chance for life. I contacted Ms. Hess about him. You must do something.” Four hours later, we It was believed that Fahad would be an excel- walked out of the Embassy with passports and lent candidate for repair, but that it should be visas. I do not know his name, but this man was done quickly. St. Joseph’s Hospital in Tampa and truly an angel. Paul Chai, MD, an extremely talented cardiac The trip to Tampa Opposite: left, top to bottom: Ms. Hardin-Gres, Dr. Campbell, Anne, and Fahad in Uganda checking in at We left Kampala at midnight to begin the 24- the airport; Anne and Fahad on the morning of surgery; hour trip back to Tampa. We stressed to Anne Fahad on the night of surgery; postoperative day one, how important it was that Fahad not cry, as we recovering; Anne and Fahad in Dr. Campbell’s garden. were concerned about a tet spell, and we sedated Opposite, right: Fahad on the night of surgery. him with Benadryl as needed. He was so weak 

NOVEMBER 2008 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS do not know why Fahad was put in front of me. II do not know what the future will hold for him, nor for his family. I do not know what God’s greater plan may be. But I do know that in a small village in Africa, a little boy laughs, and sings, and a family has been restored, thanks to the kindness of those in a country far away. There is much in the world that is wrong. But there is also much which is right. And by reaching out to a child in need, a miracle has been shared both by those who have given it, and those who have received it. And none of us are the same.

Dr. Campbell and Fahad. —Sylvia D. Campbell, MD, FACS

that he did not have the energy to cry, and the was discharged to my home on Good Friday. His trip was amazingly uneventful. platelets remained low but slowly responded to However, on his preoperative appointment at steroids. With the help of my dear friend Iris the hospital, he was noted to have a significant Alexander, the manager of the cardiac cath labo- thrombocytopenia, with his platelet count falling ratory, an outpouring of community support was to 35,000. He also was noted to desaturate to an organized for Fahad and his mother. oxygen saturation of 19 percent when he cried. He found his appetite and began to eat every- These laboratory values necessitated a week in thing he could, especially mashed potatoes. He the cardiac intensive care unit to determine that and his mother became part of my own family, he had idiopathic thrombocytopenic purpura, as well as the extended family of our community thought to be secondary to a viral infection he where my husband, my children, and all who met had caught before leaving Uganda. All of his him fell in love with his smile. He began to sing other workup, including a bone marrow analysis, and laugh all the time, and when he returned to was negative. his home, six weeks later, he was able to stand. Even with the low platelets, it was believed He grabbed everything, and was curious about that his surgery was critical, as he continued to all those who gave their support and who came desaturate and weaken. to visit. Fahad and Anne have returned to Uganda, The operation and recovery where he should have a normal life, a life full of Fahad was taken to the operating room on all the wonder and energy of any little boy, for March 18, 2008. There, Dr. Chai was able to do his broken heart is now fixed.  an amazing job repairing his heart. His defect was closed and his stenosis resected. The techni- cal skill of Dr. Chai and his team were evident as the surgery progressed. Fahad’s stenosis was just under the valve, and extreme care had to be taken not to cause injury to the valve. His post-repair intraoperative echocardiogram showed excellent normal flow, and his tiny chest was closed. His heart, once purple, was now pink. Dr. Campbell is a general surgeon in private practice Fahad had an unremarkable recovery and in Tampa, FL. 10

VOLUME 93, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS ACS Practice Patterns Survey, Part II: Prescribing habits among surgical specialties by Charles M. Balch, MD, FACS; and Thomas R. Russell, MD, FACS

11

NOVEMBER 2008 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS ith the continued advances and scribe more than 10 drugs each week; 56 percent widespread availability of safer, more prescribe more than 20 drugs per week, and 45 effective drugs and other systemic percent prescribe more than 25 in the course of a agents, the surgeon of today is en- week. Among the surgical specialties, the top three gaWged in a much more holistic approach to treat specialties prescribing 20 or more drugs each week the whole patient. Indeed, surgeons of all surgi- were specialists in trauma/critical care, urology, cal specialties prescribe medications frequently and otolaryngology–head and neck (see Figure 1, as an integral component of their care for the page 13). Following is a list of the percentages of surgical patient. surgeons within specific surgical specialties who Until now, there were very little data that issue 20 or more prescriptions per week: showed how frequently surgeons prescribe drugs and which classes of drugs were used within each • Trauma/critical care 90% of the surgical specialties. To address this issue, an • Urology 77 electronic survey of ACS members was conducted • Otololaryngology–head and in fall 2007. The response rate was impressive: neck surgery 71 4,207 individuals participated, representing the • Cardiovascular 66 broad range of practice settings and surgical spe- • Colon and rectal surgery 62 cialties. Nearly 45 percent of the respondents work • Vascular surgery 62 in a university/teaching hospital, 39 percent are in • Surgical oncology 61 private practice, and the remainder provides care • General surgery 58 in other environments. The largest percentage of • Pediatric surgery 57 respondents (40 percent) classified themselves as • Plastic and maxillofacial surgery 35 general surgeons, and the other 60 percent rep- • Breast surgery 25 resented the majority of surgical specialties. The breakdown of surgical subspecialties was very Not surprisingly, most of these prescriptions similar to that of the ACS membership overall. are for drugs used in perioperative care, such as analgesics, antibiotics, and antiemetics. However, Prescribing patterns it is interesting to note that surgeons report This study, the largest ever published on this prescribing a range of medicines for respiratory, subject, clearly indicates that surgeons in a variety cardiovascular, gastrointestinal, critical care, of settings and specialties commonly prescribe a and thrombosis conditions on a weekly basis wide range of medications. The majority of re- (see Tables 1-3, page 14). Furthermore, half of spondents (80 percent) said that, on average, they the study participants said that, within the past or trainees working under their supervision pre- year, they have ordered or prescribed a recently approved therapy or one under investigation. Following are the most common classes of drugs Dr. Balch is professor prescribed, on average, for five or more per week of surgery, oncology, and dermatology at The by survey respondents: Johns Hopkins School of Medicine, Baltimore, • Analgesics 78% MD. • Antibiotics 66 • Antiemetics 42 • Antithrombosis agents 33 • Anti-inflammatory agents 38 • Gastrointestinal agents 36 • Anticoagulation agents 26 • Cardiovascular agents 23 • Diuretics 16 • Respiratory 17 • Hormones 7 12

VOLUME 93, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Figure: Drug orders by specialty Drug Orders

CountCount of specialty 90.00%

80.00%

70.00% specialty General Surgery 60.00% Otolaryngology – Head and Neck Surgery Vascular Surgery 50.00% Colon and Rectal Surgery Urology Trauma/Critical Care 40.00% Cardiothoracic Surgery Pediatric Surgery 30.00% Plastic and Maxillofacial Surgery Breast Surgery Surgical Oncology 20.00%

10.00%

0.00% More than 21-25 16-20 11-15 6-10 5 or less None (blank)No 26 response General Surgery 45.34% 13.15% 16.83% 12.27% 7.85% 2.62% 1.21% 0.74% Otolaryngology – Head and Neck Surgery 60.00% 10.98% 13.73% 9.80% 2.35% 1.18% 0.78% 1.18% Vascular Surgery 49.06% 12.74% 12.26% 13.21% 9.91% 2.36% 0.00% 0.47% Colon and Rectal Surgery 45.50% 16.93% 17.99% 10.05% 4.76% 3.17% 0.53% 1.06% Urology 65.12% 12.21% 14.53% 5.23% 2.33% 0.00% 0.58% 0.00% Trauma/Critical Care 83.53% 6.47% 5.29% 1.76% 1.18% 0.59% 0.00% 1.18% Cardiothoracic Surgery 55.69% 10.18% 11.98% 10.78% 7.19% 3.59% 0.60% 0.00% Pediatric Surgery 46.63% 9.82% 15.95% 10.43% 13.50% 3.07% 0.61% 0.00% Plastic and Maxillofacial Surgery 18.59% 16.03% 17.31% 24.36% 20.51% 3.21% 0.00% 0.00% Breast Surgery 14.40% 10.40% 15.20% 22.40% 27.20% 10.40% 0.00% 0.00% Surgical Oncology 48.78% 12.20% 13.01% 13.01% 8.94% 2.44% 1.63% 0.00%

drug orders per week

13

NOVEMBER 2008 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Table 1: Analgesics by specialty The different classes of No drugs were prescribed with >20 11-20 6-10 1-5 Never response different frequency among Breast Surgery 8.00% 22.40% 37.60% 30.40% 1.60% 0.00% the surgical specialties. Fol- Cardiothoracic Surgery 31.74% 27.54% 25.15% 13.17% 1.20% 1.20% lowing is a list of subspecial- Colon and Rectal Surgery 24.34% 34.39% 29.10% 11.11% 1.06% 0.00% ties with the most common General Surgery 32.93% 33.74% 23.34% 8.58% 1.14% 0.27% class of drugs prescribed (for Otolaryngology– 10.20% 20.39% 40.78% 27.06% 1.18% 0.39% average use of more than 10 Head and Neck Surgery per week): Pediatric Surgery 33.74% 25.15% 26.99% 13.50% 0.61% 0.00% Plastic and Maxillofacial 21.15% 23.08% 39.10% 16.03% 0.64% 0.00% • Analgesics Surgery Trauma/critical care 91% Surgical Oncology 31.71% 26.02% 25.20% 14.63% 2.44% 0.00% General surgery 66 Trauma/Critical Care 80.59% 10.59% 6.47% 2.35% 0.00% 0.00% Pediatric surgery 59 Urology 17.44% 26.16% 36.63% 18.60% 1.16% 0.00% Colon and rectal surgery 59 Vascular Surgery 27.83% 26.89% 30.19% 14.62% 0.47% 0.00% Cardiothoracic surgery 59 Surgical oncology 58 Table 2: Antibiotics by specialty Vascular surgery 54 No >20 11-20 6-10 1-5 Never response • Antibiotics Breast Surgery 3.20% 6.40% 24.00% 64.00% 0.80% 1.60% Trauma/critical care 78% Cardiothoracic Surgery 16.77% 22.75% 30.54% 28.14% 1.80% 0.00% Urology 72 Colon and Rectal Surgery 8.99% 17.99% 32.80% 38.10% 1.06% 1.06% Otolaryngology 53 General Surgery 12.94% 25.96% 33.87% 25.82% 1.01% 0.40% Cardiovascular 40 Otolaryngology– 25.88% 27.45% 34.51% 1.76% 0.00% 0.39% General surgery 39 Head and Neck Surgery 1 Pediatric surgery 39 Pediatric Surgery 15.95% 23.31% 34.97% 23.31% 0.00% 2.45% Plastic and Maxillofacial 10.26% 21.15% 38.46% 30.13% 0.00% 0.00% • Antiemetics Surgery Trauma/critical care 49% Surgical Oncology 6.50% 21.14% 38.21% 30.08% 3.25% 0.81% General surgery 31 Trauma/Critical Care 38.82% 38.24% 15.88% 6.47% 0.00% 0.59% Colon and rectal surgery 21 Urology 36.63% 34.88% 21.51% 6.98% 0.00% 0.00% Surgical oncology 21 Vascular Surgery 8.96% 21.23% 36.32% 32.55% 0.47% 0.47% • Antithrombosis agents Table 3: Antiemetics by specialty Trauma/critical care 49% Vascular surgery 32 No >20 11-20 6-10 1-5 Never response Surgery 1.60% 3.20% 11.20% 54.40% 28.80% 0.80% • Anti-inflammatory agents Cardiothoracic Surgery 10.78% 13.77% 23.95% 44.31% 5.99% 1.20% Trauma/critical care 37% Colon and Rectal Surgery 3.70% 16.93% 20.63% 46.03% 11.11% 1.59% Otolaryngology 21 General Surgery 11.94% 19.25% 26.56% 37.29% 3.76% 1.21% Cardiothoracic 19 Otolaryngology– 1.57% 3.53% 13.33% 60.78% 8.82% 1.96% Urology 17 Head and Neck Surgery 1 Pediatric surgery 17 Pediatric Surgery 5.52% 7.98% 18.40% 53.99% 13.50% 0.61% Surgical oncology 14 Plastic and Maxillofacial 5.13% 8.97% 19.87% 53.21% 9.62% 3.21% General surgery 14 Surgery Surgical Oncology 8.94% 12.20% 27.64% 41.46% 8.94% 0.81% • Gastrointestinal agents Trauma/Critical Care 21.18% 27.65% 21.18% 26.47% 2.35% 1.18% Trauma/critical care 43% Urology 3.49% 4.65% 9.30% 63.37% 17.44% 1.74% Colon and rectal surgery 24 Vascular Surgery 3.30% 10.38% 18.87% 48.11% 17.45% 1.89% continued on next page 14

VOLUME 93, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Cardiothoracic 21 ther prescribed, recommended, or administered General surgery 20 oncology-related hormone agents. In addition, Otolaryngology 20 30 percent did so for chemotherapeutic agents Surgical oncology 15 and growth factors, and 21 percent prescribed monoclonal antibodies.* • Cardiovascular agents Cardiothoracic 51% Conclusion Trauma/critical care 42 These data provide new insights into the prac- Vascular 30 tice habits of surgeons caring for their patients. General surgery 12 There were differences in both the types of drugs used and the frequency of prescribing them • Diuretics among the various surgical specialties. Most Cardiothoracic 39% notable was the high frequency with which all Trauma/critical care 20 surgeons prescribed various drugs and systemic agents in the daily care of their patients.  • Respiratory Trauma/critical care 38% Cardiothoracic 23

• Hormones Urology 20% Breast surgery 6

Within surgical specialties, there were vary- ing prescribing patterns as well. For example, trauma/critical care specialists prescribed the entire range of drugs classes, but the nature of their patient care caused them to most fre- quently prescribe analgesics (91 percent pre- scribe 10 or more/week), antibiotics (78 percent), antiemetics (49 percent), and antithrombosis agents (49 percent). General surgeons most frequently prescribed analgesics (66 percent), antibiotics (39 percent), antiemetics (31 per- cent), and gastrointestinal agents (20 percent). Urologists most frequently prescribed antibiotics and hormones. Dr. Russell is The data in this survey did not present a suf- Executive Director of ficient sample size to assess the use of systemic the College in Chicago, IL. cancer agents. However, a similar survey was conducted in 2006 among members of the Soci- ety of Surgical Oncology. Within this specialty, the use of systemic agents for cancer manage- ment would be prescribed more frequently as a component of the multidisciplinary cancer management. Thus, among the 532 surgical oncology respondents, two-thirds each week ei- *Balch CM. Prescribing patterns of surgical oncologists: Are we surgeons, oncologists, or both? Results of a society of surgical oncology survey. Ann Surg Oncol. 2007;14:2685-2686. 15

NOVEMBER 2008 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS

he history of trauma parallels the history these wounded troops. Every SVS has described of war, and there is no doubt that many this care as being outstanding. of the principles that guide trauma care The medical personnel at LRMC—consisting of are being rewritten during the ongoing members of the U.S. Army, Navy, and Air Force— Tglobal war on terrorism currently being waged face challenges unlike those at any other trauma in Iraq and Afghanistan. In fact, this conflict has center. First, the injuries being inflicted on our the lowest overall case fatality rate of any war in troops are complex and of extremely high acuity. U.S. history. This outcome is truly remarkable, The typical injury pattern follows an explosion considering that the care given to these wounded and may consist of blast, burn, blunt, and pen- troops spans three different continents. In order etrating injuries combined. Not uncommonly, the to better appreciate these advances in military injured troop has undergone one or two operative medicine, the leadership of the American College procedures before arriving in Germany, including of Surgeons Committee on Trauma (COT) and vascular shunting followed by definitive vascular of the American Association for the Surgery of repair, damage control laparotomies, decompres- Trauma, working in conjunction with the U.S. sive craniotomies, and stabilization of fractures military, developed the Senior Visiting Surgeons or the initial phase of fluid resuscitation for burn (SVS) program. wounds. Most of these patients leave the combat The global objective of this program is to theater hospital within 24 to 48 hours of their establish scientific exchange between the lead- injury, flying eight hours to land at Ramstein Air ers in civilian trauma care and our experienced Force Base in Germany, a short distance from military counterparts. The SVS program is also LRMC. The patients arrive together in busloads meant to rapidly forward the lessons learned in and are triaged to either surgical wards or the the military realm to the civilian sector. To date, intensive care unit. It is not uncommon to receive the SVS efforts have been centered at the larg- five to seven critically injured patients simultane- est U.S. military medical center outside of the ously at LRMC. Fortunately, via the Web-based country’s borders: Landstuhl Regional Medical Joint Patient Tracking Application, the data on Center (LRMC) in Landstuhl, Germany. LRMC these patients (including operative notes, com- is the receiving hospital for all injured troops puted tomography [CT] scans, and so on) can be being evacuated from Iraq and Afghanistan and reviewed long before their arrival. the last stop for these patients before transfer Once in Germany, the wounded troops undergo back to the U.S. a reevaluation of all injuries. Invasive lines are The SVS program, which was initiated in 2006, changed and laboratory values rechecked, and involves a two- to four-week rotation at LRMC many undergo additional surgical procedures as part of participants’ trauma/critical care ser- such as closure of abdominal wounds, burn or soft vice. The civilian surgeons rotating at LRMC tissue wound debridements, muscle compartment have provided scientific seminars, given surgical releases if needed, and more definitive treatment grand rounds, instigated or mentored scientific of fractures. Scanning for deep venous thrombo- research, assisted in preparing for trauma center sis (or pulmonary emboli) is a high priority. Steps verification, attended the peer review conferences are taken to identify and control infections and (which also span three continents), and, most emphasis is placed on the provision of adequate importantly, were privileged to participate in nutrition. Anxious families are contacted and the surgical and critical care being rendered to updated as to the condition of their loved ones arriving in Germany. All of these activities are Opposite, top photo: Helicopter landing outside the done on a strict timeline, with the goal of trans- emergency department, bringing injured patients. porting stabilized patients to the continental Center: “Heroes Highway” (left to right): Joshua Alley, MD; Col. Jay Johannigman, MD, FACS; Colonel U.S.—to Walter Reed Army Medical Center; Jenkins; Dr. Knudson; Todd Rasmussen, MD, FACS; National Naval Medical Center in Bethesda, MD; and Carl Baker, MD. or Brooke Army Medical Center in San Antonio, Bottom: Dr. Knudson participating in side-by-side TX—as soon as feasible (typically 24 to 48 hours craniotomies in the operating room of the 332nd. later). As this next phase of transport involves 17

NOVEMBER 2008 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS at least 12 hours in flight (18 hours to Brooke), 3. To provide consultation for the continued there is no room for error, and adequate prepara- development of the military trauma system tion of each patient before transport is a dictum. 4. To foster the educational process needed to Every laboratory value, line, tube, and monitor translate the lessons learned in Operation Iraqi must be corrected, secured, and accurate before Freedom and Operation Enduring Freedom to leaving LRMC. civilian trauma care both for daily use and in Despite all of these challenges, the remark- preparation for mass casualties and disasters able care rendered at LRMC is delivered with 5. To explore the potential development of the highest professionalism and with the deep- programs whereby civilian trauma surgeons est compassion. Indeed, this was reaffirmed by might provide assistance to our military surgical members of the ACS/COT Verification Review colleagues Committee who recently verified that LRMC met (and often exceeded) all of the criteria for a 2008 Joint Theater Conference level II trauma center as defined by the COT.* (The observations of some of the SVSs while One of the initial goals of our mission to Iraq at Landstuhl have been published in two peer- was to participate in the Joint Theater Trauma reviewed articles†). Following the lead of the SVS System [JTTS] Chief Conference, The Con- program, civilian neurosurgeons, orthopaedic tinuum of Trauma Care in the Matured U.S. surgeons, and vascular surgeons have also vol- Central Command/European Command Areas unteered their services at LRMC. of Responsibility. I was honored to be accompa- Although the experience at Landstuhl was nied on the entire trip by Col. Donald Jenkins both educational and fulfilling for the civilian (USAF), MD, FACS, who met me in Germany, surgeons, many of us felt that we were missing assured that I got through all checkpoints en the “front end” of care being delivered in the route to Iraq, and attended to my security at combat zone. We wanted to understand more every level. We were both invited to present at fully the challenges of working in combat sup- port hospitals and gain experience in the initial treatment of these often devastating injuries. I Recent publications describing was recently offered the incredible opportunity military treatment modalities to visit the Air Force’s 332nd Air Expeditionary Wing (AEW) Theater Hospital located at Balad • Chung KK, Blackbourne LH, Wolf SB, et al. Air Base in Iraq. While I prepared for this ad- Evolution of burn resuscitation in Operation Iraqi venture, I formulated the following list of my Freedom. J Burn Care Res. 2006;27:606-611. objectives for taking this step: • Schreiber MA, Perkins J, Kiraly L, et al. Early 1. To assist in codifying the important trauma predictors of massive transfusion in combat casual- surgical lessons learned during the current ties. J Am Coll Surg. 2007;205:541-545. conflict in order to preserve them for future • Spinella PC, Perkins JG, McLaughlin DF, et conflicts al. The effect of recombinant activated factor VII 2. To identify areas that might benefit from on mortality in combat-related casualties with se- vere trauma and massive transfusion. J Trauma. collaborative research involving both military 2008;64:286-294. and civilian trauma research groups • Holcomb JB. Damage control resuscitation. *Knudson MM, Mitchell FL, Johannigman JA. First trauma J Trauma. 2007;62:S36-S37. verification review committee site visit outside the U.S.: • Rasmussen TE, Clouse WD, Peck MA, et al. Landsthul Regional Medical Center, Germany. Bull Am Coll Development and implementation of endovascular Surg. 2007;92:16-19. capabilities in wartime. J Trauma. 2008;64:1169- †Moore EE, Knudson MM, Schwab CW, Trunkey DD, 1176. Johannigman JJ, Holcomb JB: Military-civilian collaboration • Holcomb JB, Champion HR, Pruitt BA, et al. in trauma care and the senior visiting surgeon program. Advances in combat casualty care: Clinical outcomes New Engl J Med. 2007;357:2723-2727; and Trunkey DD, from the way. J Trauma. 2008;64(suppl):S1-S205. Johannigman JA, Holbomb JB. Lessons relearned. Arch Surg. 2008;143:112-114. 18

VOLUME 93, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS this inaugural trauma confer- Figure ence, facilitated by Col. George Costanzo (USAF), who was at that time serving as the direc- tor of the JTTS. Surgeons from the various echelons of care, from far forward surgical units to the combat support hospitals throughout Iraq, attended the conference and presented their experience in treating various injuries and the challenges of dealing with the ebb and flow of patient care demands. The for- mal educational portion of the conference highlighted some of the developments in combat casualty care that are clearly contributing to the low fatal- ity rate in this war. Although a discussion of these treatment modalities is beyond the scope of this article, they are well described in recent publications (see boxed item, page 18) and can be summarized as follows: • Renewed use and redesign of tourniquets • Screening for symptoms of minimal brain that can be self-applied injury in all injured troops • Use of innovative hemostatic dressings for • Redesign of personal protective gear open wounds • Adoption of a massive transfusion protocol The JTTS that advocates for more liberal use of freshly fro- zen plasma and platelets along with packed red Care of the injured in Iraq and Afghanistan cells (so-called damage control resuscitation) begins at the site of wounding with self-aid and • Use of point-of-care thromboelastogram buddy care. Further care in the field may be results to guide transfusion practice rendered by the combat medic as dictated by the • Recognition of the advantages of using fresh guidelines promulgated by the Committee for whole blood Tactical Combat Casualty Care. When appropri- • Use of the procoagulant-activated factor ate, or if nearby, the casualty may be moved to VII early in patients requiring massive transfu- a forward operating base and the battalion aid sions station (Level II), where field medics initiate • Aggressive use of vascular shunts for tem- additional first aid for the wounded. Forward porary control of vascular injuries surgical teams are located in many locations • Development of endovascular capabilities throughout the theater and are designated as in combat support hospitals level IIB facilities, capable of conducting life • Guidance of burn resuscitation using a and limb stabilization in far-forward and aus- standardized clinical practice guideline algorithm tere conditions. The patient is then transferred that travels with the patient via helicopter to the combat surgical support • Adoption of damage control strategies for hospitals (Balad and Baghdad in Iraq). These abdominal, vascular, and orthopaedic injuries facilities are designated as level III facilities and 19

NOVEMBER 2008 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS have more complete surgical teams, including The trauma experience at Balad surgical specialists and intensive care unit (ICU) facilities. The current level III centers in the During the second part of my visit, I was able to theater may be roughly equated as civilian level integrate myself into the surgical team and par- II trauma centers in the U.S. The surgical care ticipate as much as possible in patient care and in at the combat support hospitals is intended to be the operating room at the 332nd AEW hospital. more definitive. Following stabilization within This hospital serves not only as a level III combat the theater, the patients are evacuated to the support facility but also as the primary collection level IV facility at LRMC via the Air Force aero- point for casualties requiring evacuation out of medical evacuation system. The level V facilities theater. The initial configuration of the hospital are the military trauma receiving hospitals in consisted of more than 30 interlinked tents, but the U.S (see Figure, page 19). in 2007, the 332nd moved into a new fixed facility This complex trauma system is coordinated by (see photos, page 21). The hospital consists of an a number of measures. Leadership is provided emergency department, four operating rooms, an by the JTTS director, who oversees all echelons ICU, and a large surgical ward (see photos, pages of care throughout Iraq and Afghanistan. The 22-23). There are also limited outpatient facili- second important component is the joint patient ties, a well-stocked blood blank, advanced imag- tracking application, the Web-based system ing capabilities, and a clinical laboratory. The allowing entry of patient data at each level of majority of patients arrive by helicopters that care. There are also trauma program managers land just outside the emergency department. at various locations in the theater system who From the desk in the emergency department, supply the initial entries into the joint theater one can stand and see the entire room and ob- trauma registry, a robust trauma database that serve all activities, which is an advantage during now contains data on several thousand injured mass causality situations. The week before my troops and into which data are entered at each arrival, the hospital received 32 casualties dur- level of care. Research personnel have also been ing the course of 90 minutes, victims of a suicide deployed into theater hospitals. The very timely bomber in a market. The teams divide them- performance improvement process is facilitated selves efficiently among the casualties, blood and by the weekly clinical video teleconference, plasma is delivered promptly, laboratory results which connects the military medical units in are back within minutes, and ultrasound units Iraq and Afghanistan by audio to LRMC and for FAST (Focused Assessment by Sonography Walter Reed and to the U.S. Army facilities in in Trauma) exams are readily available. There San Antonio (audio and visual) during which are two multidetector CT scanners just off the individual patients are discussed and their care main room and immediately available, as is the reviewed at every level. This coordinated pro- radiologist. cess has also resulted in the development of a The surgical team at the time of my visit con- number of trauma clinical practice guidelines sisted of eight general surgeons (two of whom that are considered standards of care within the were also vascular surgeons and two trained tho- theater trauma system, including prophylaxis racic surgeons), two orthopaedic surgeons, two for venous thromboembolic complications, an- oral-maxillofacial surgeons, two neurosurgeons, tibiotic use, prevention of hypothermia, and the one ear-nose-throat surgeon, one urologist, and management of specific injuries such as burns, two ophthalmologists. The team is supplemented vascular trauma, and traumatic brain injuries.‡ by emergency physicians, internists, physician This highly functional trauma system is truly re- assistants, nurses, and anesthesiologists. There markable when one considers that it was largely are four operating rooms that are fully staffed developed and refined during the war. seven days a week. A “normal” daily schedule consists of somewhere between 12 to 15 semi- ‡Eastridge BJ, Jenkins D, Flaherty S, et al. Trauma system development in a theater of war: Experiences from Operation elective cases on patients already in the hospi- Iraqi Freedom and Operation Enduring Freedom. J Trauma. tal; however, rooms are always ready to provide 2006;61:1366-1373. immediate care to the incoming injured and it 20

VOLUME 93, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS The original 332nd as a series of tents (top), and the newer hospital with Kevlar protective roof over a solid structure.

21

NOVEMBER 2008 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Entrance to the emergency department at the 332nd.

is not unusual to have two patients being oper- malnourishment of many Iraqi patients, affect- ated upon simultaneously in the same operating ing their ability to heal these large, high-energy room theater. combat wounds. Provision of total parenteral The ICU is an open unit with beds separated nutrition is limited by severe infectious compli- only by curtains. Most of the patients in the cations and the use of enteral nutrition is often ICU are host nationals (Iraqi civilians, Iraqi limited by open abdomens, enteric fistulae, or military, contractors, and so on). The U.S. troops intra-abdominal infections. An additional chal- are evacuated to LRMC in Germany usually lenge faced by the military medics is the provi- within 24 hours of their arrival if their condi- sion of ongoing care for the patients who are tion permits (see photo, page 24). This open ICU Iraqi nationals. The current state of the medical presents multiple challenges, including the need care in Iraq is very austere and limited even in to meet the care of men, women, and children the most rudimentary components of health alike. The difficulties in maintaining precautions care. This became most apparent in the process against nosocomial infections are evident when of discharge planning, as the military medics walking through such a busy facility located in attempted to return their Iraqi patients into the middle of an austere and warm environment. a health care system vastly different than the An additional clinical challenge is the state of standards most U.S. physicians are accustomed 22

VOLUME 93, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS The emergency department at the 332nd.

to. Sadly, the media have directed little attention The extent and scope of injuries normally include to the humanitarian side of the mission in the multiple sites, soft tissue as well as orthopaedic Middle East, especially by our deployed medical injuries, often with concomitant vascular com- personnel. promise. The appropriate trauma evaluation of On my first day on-call, we received several these patients includes a thorough examination civilians injured by gunfire. Two were very young of all areas of the body and must take into consid- children who had sustained gunshot wounds to eration both blunt and penetrating mechanisms the head. They were examined, intubated, and of force transmission. The variety and the size had lines established and CT scans performed of objects removed from wounds as the result (and read by the radiologist and the neurosur- of explosive devices are unlike anything seen in geons), and both children were taken to the our country. operating room where two craniotomies were My last day at the 332nd was the hardest. initiated side by side by two neurosurgeons A U.S. soldier was brought in with four tour- within 20 minutes of arrival. Most U.S. trauma niquets in place after a devastating explosive centers would find this scenario very difficult injury. He was in profound shock and taken di- to replicate. rectly to the operating room where four surgical During my short stay in Balad, in addition to teams assembled around his four limbs as well as a craniotomy, I participated in several wound his neck, where he had an obvious penetrating debridements, abdominal reexplorations, fasci- injury. Unfortunately, the patient expired (one of otomies, vascular repairs, amputations, and a the few deaths in this operating room, which is thoracotomy. The wounds encountered in this remarkable in itself). Nearly the entire hospital combat environment are significantly different staff immediately assembled for prayers and for than those common in civilian trauma care. The the draping of the American flag over his body majority of injuries are related to either high- (Patriot’s Detail). That night, all the surgeons energy missile wounds (AK-17, M-16) or to blast involved in this case met in the “lounge” on the injuries (improvised explosive device, mortar rooftop of the hospital (affectionately referred rounds, explosive formed projectiles, and so on). to as “OR #5”) and discussed the case and what 23

NOVEMBER 2008 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS needed equipment—including ventilators, pumps, medica- tions, nutrition, monitors, and so forth—is an art in itself, and loading it all into the back of these huge cargo planes without incident in the dark of night in the middle of the des- ert is like a well-orchestrated dance. Patients with less severe injuries (typically heading for ward care at LRMC or Walter Reed) are loaded first, to be attended by nurses and medi- cal technicians. (These planes can transport as many as 50 patients at a time.) The back of the plane is reserved for the intensive care patients, each of whom has his or her own CCATT team. Each team con- sists of a critical care physician (surgeon, emergency physician, anesthesiologist, cardiologist, and so on), an ICU-qualified nurse, and a respiratory thera- pist. During the flight, blood gases are monitored, as are electrolytes using point-of-care technology; nutritional support is continued; and narcotics and The flight line where injured patients are loaded for transport to Germany. sedatives are administered as needed. The plane is cold and noisy, and the monitor alarms must be visible because they might have been done differently. This was cannot be heard above the background noise of truly a unique mortality conference and, taken the jet engines. Despite these challenges, this together with the weekly video-teleconference ICU in the air is highly effective and has pro- described previously in this article, can serve vided safe transport for stabilized (though not as an excellent model for civilian trauma cen- necessarily stable) critically injured troops with ters. the goal of getting them back to the U.S. as soon as possible. It serves as an excellent model of an CCATTs: Critical care in the air evacuation process that might be used during a natural or man-made disaster. Another unique experience was my ability to observe the transport of injured troops from Directives for ACS Fellows Iraq to Landstuhl and then from Landstuhl to Andrews Air Base under the care of the Air Force For the Fellows of the American College of Critical Care Air Transport Teams (CCATT). Surgeons who are not current members of the The transport of critically ill patients and all the military, what can we do to provide support and 24

VOLUME 93, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS assistance to our deployed military colleagues? I airmen, sailors, and marines the very best would submit the following directives: trauma care that we can deliver. In addition, 1. We need to critically and scientifically evalu- we owe the patients in our trauma centers at ate the lessons learned by the military surgeons home the chance to benefit from the scientific during this conflict and be cognizant of situations discoveries coming out of this conflict—that is, where we can apply them in civilian trauma after all, our obligation as surgeons.  care. 2. As many of the senior military surgeons will Acknowledgments be separated from their respective military posts before the next conflict, we must assist them in I owe special thanks to those who facilitated my trip developing a “repository” for these important to Iraq, including Col. Bryan Funke; Col. Jay Johan- lessons, so that they can be passed on to the next nigman, MD, FACS; Col. Donald Jenkins, MD, FACS; Col. Bryan Gamble; Col. George Costanzo; and Col. Lee generation of military medics. Payne. I would also like to acknowledge the members 3. We should continue to work with the mili- of the Balad Association of Doctors Anaconda Surgical tary toward the goal of developing a worldwide Society who are superb surgeons, dedicated physicians, military trauma system, using the ACS COT and exemplary individuals. Verification and Systems Consultation Commit- It was a privilege to work with everyone, including tees. Dr. Johannigman; Joshua Alley, MD; Carl Baker, MD; 4. We should consider innovative programs Nabil Habib, MD, FACS; Solon Hughes, MD, FACS; that would allow civilian surgeons to fill posts Todd Rasmussen, MD, FACS; Jay Sampson, MD, FACS; now occupied by military physicians. For ex- and Scott Davidson, MD. ample, civilian surgeons could work at Veterans Affairs Hospitals, military hospitals in the U.S., or (after proper training) fly CCATT missions from LRMC to Andrews in order to relieve our military colleagues. Perhaps these nondeployable positions could be filled by recent graduates of surgical and specialty residency programs as a method of paying back medical school debt. 5. Finally, we have an obligation to assist in the humanitarian medical efforts in a stabilized Middle East.

Honor and privilege It has been a distinct honor and a privilege for me to have been given such an up-close and Dr. Knudson is profes- personal view of this highly organized and suc- sor of surgery, Univer- cessful trauma care system put in place by the sity of California– U.S. military. For those readers who have loved San Francisco, and ones deployed in Iraq or Afghanistan, be assured Vice-Chair of the ACS that, should they be injured, they will receive Committee on Trauma. trauma care that is unsurpassed by any trauma system here in the U.S. My time at LRMC and at the 332nd have been life-changing for me, both personally and professionally, and I look forward to a continued association with my military colleagues as we work together toward establishment of a worldwide military trauma system. For no matter what your views are on this war or any war, we owe our brave soldiers, 25

NOVEMBER 2008 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS or chapters of the College. In those cases, staff may provide advice and resources on the best way to deal with the state legislation or regulation under consideration. These issues include health system reform, provider taxes, office-based surgery/ambulatory surgery regulation, imaging restric- state tions, licensure/maintenance of licensure, and laser surgery regulation, among others. legislative During 2008, State Affairs monitored more than 145 bills in 35 states through use of an online legislative and regula- activity tory search service. The follow- ing bills are a representative sample of the types of legisla- tion that was monitored. by Melinda Baker, State Affairs Associate, Medical liability reform Division of Advocacy and Health Policy Because of a number of fac- tors, the last few years have seen a significant decrease in the number of bills dealing with he State Affairs area of the College’s Division of Advocacy large-scale reforms related to and Health Policy is responsible for monitoring and track- the Medical Injury Compensa- ing legislation at the state level. From January to August tion Reform Act. The decrease 2008, more than 85,000 bills had been introduced in state is largely the result of the cap legislaturesT across the country; this is approximately half the on noneconomic damages that number of bills introduced by this time last year. This difference now exists in more than 30 exists, in large part, because 2008 is an election year. Election states and because many states years, especially presidential election years, are traditionally have enacted other significant “slower,” legislatively speaking. reforms. The states without Because there are so many bills with so many health-related reforms have political climates topics introduced in state legislatures, it is important to focus that are unfavorable to this the College’s State Affairs resources. This year, the Health Policy type of legislation or constitu- Steering Committee directed State Affairs to focus on the follow- tional barriers. Once again this ing five primary issues: year, most of the legislation re- • Medical liability reform lated to liability was defensive, • Trauma with many of these battles tak- • Uniform Accident and Policy Provision Repeal (UPPL) ing place not at the statehouse • The Uniform Emergency Volunteer Health Practitioners Act but in the courts. (UEVHPA) One state that has contin- • Scope of practice issues ued to fight for a legislative However, there are issues beyond these categories that are solution to its liability crisis is brought to the attention of State Affairs by individual surgeons Tennessee. This year, Tennes- 26

VOLUME 93, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS see passed S.B. 2001/H.B. 1993. These bills were passed S.B. 938 in 2005. This bill placed restric- introduced in 2007 and were signed by Gov. Phil tions on who could view the records and what Bredesen (D) in May 2008; they will go into effect information the records would contain in order October 1, 2008. to comply with HIPAA, while still allowing for The bills originally included reforms such as a peer review. The legislature also determined that $250,000 stacked cap on noneconomic damages the amendment did not apply to records created (maximum $500,000, with $250,000 for physi- or incidents occurring before Amendment Seven cians and $250,000 for facilities per incident); was adopted. a sliding scale for attorneys’ fees; affidavit of The Florida Supreme Court recently issued an merit requirements; and periodic payment for opinion on two cases involving Amendment Seven damages exceeding $75,000. All of these reforms and the subsequent clean-up language included were deleted from the bill, which was amended in S.B. 938. The court ruled that Amendment and passed to include only the requirement of Seven is self-executing and retroactive and its a Certificate of Good Faith before a claim may provisions apply to records existing before its be filed (and 60 days notice before the claim is passage. Essentially this ruling makes any in- filed) and to provide for sanctions against any formation—even information documented before attorney found to be violating the notion of a the bill’s passage—not only discoverable but also “good faith” case. admissible in court. Illustrating the role of the judiciary in medical The Florida Chapter of the College is working liability reform, the caps on damages established with other members of the Florida medical com- in Illinois and Georgia are being challenged in munity on this matter. (To read the full court the courts. opinion, visit http://www.floridasupremecourt. In Georgia, a state court ruled that the org/decisions/2008/sc06-688.pdf.) $350,000 cap on noneconomic damages (passed in 2005) violates the state’s equal protection prin- Trauma ciples. The Georgia Supreme Court has agreed to hear the case, although no hearing date had System development been set at press time (Parks v. Wellstar, Case Two more states, Kentucky and South Dakota, #2007CV135208). passed legislation this year that creates a legisla- A case challenging the $500,000 cap in Illinois tively recognized “trauma system.” is currently being heard in the state’s Supreme In mid-March 2008, South Dakota’s Gov. M. Court. In this case, a Cook County Circuit Court Michael Rounds (R) signed S.B. 200, which es- originally ruled in November 2007 that the cap tablishes a statewide trauma network. This leg- was unconstitutional because it violated the sepa- islation directs the Department of Public Health, ration of powers clause. A ruling is not expected along with the Department of Public Safety, to in this case until at least the middle of this month develop, implement, and administer a trauma (Lebron v. Gottlieb Memorial Hospital). care system. The Department of Public Health Although caps are not at issue in this case, is still working on the rules, and public hearings a very important battle is being fought in the will be held once the draft rules are published. Florida court system. In November 2004, Florida The legislation mandates that the rules include voters passed several constitutional amendments. the following:1 Amendment Seven (also known as the “Patient’s • Designation of the levels of trauma hospitals Right to Know about Adverse Medical Incidents”) and the resources each hospital is required to have allowed for open medical records and required the concerning personnel, equipment, data collection, release of records related to any adverse incidents and organizational capacity for each level that could have led to patient harm. Because of • Prehospital emergency medical services tri- concerns that this amendment might violate the age and treatment protocols for trauma patients federal Health Insurance Portability and Ac- • Requirements for collection and release of countability Act (HIPAA) and adversely affect trauma registry data the peer review process, the Florida legislature The South Dakota legislation does not allocate 27

NOVEMBER 2008 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS any special funds for the development or mainte- go up to an additional $30 for speeding. The legis- nance of the system; rather, the funds are coming lation also includes a $4 fee on each set of license from the Department of Public Health’s budget. plate tags and an additional $10 for each reckless The Kentucky legislature enacted H.B. 371 to and/or careless driving offense. establish a statewide trauma system. H.B. 371 The bill also creates an escrow account and creates an advisory committee that will work with mandates that whenever the trauma fund exceeds the statewide trauma care director to develop and $25 million, the remaining funds will be trans- implement a statewide trauma care system. This ferred to the escrow account and not be returned system must include (but is not limited to) de- to the general revenue fund. velopment of guidelines and protocols, voluntary hospital trauma center verification (either by the Injury prevention ACS or the Department of Public Health), and lo- A record number of surgeons used the College’s cal and regional triage and transport protocols.2 Surgery State Legislative Action Center at the This legislation also creates a trauma care end of July, with more than 200 letters sent to system fund that is a restricted account of state legislators asking them to support S. 2772. This general fund appropriations. Other grants and legislation would have provided important and any money left in the fund at the end of the year reasonable regulation of all-terrain vehicles will carry over to the following year. The fund (ATVs) operated by minors and would have ad- shall be used to pay for several things, including dressed concerns related to recreational use of “support for uncompensated care…in a verified ATVs by those in the age range of 14 to 16 years trauma center.”3 and would have prohibited operation by individu- als younger than 14. Funding The bill was stalled in the Ways and Means Com- Mississippi passed H.B. 1405, which is expected mittee and was released on July 31, the last day of to generate approximately $32 million for the the session, with a recommendation for passage. state’s trauma system. The money generated by The bill was read at midnight, and two unfriendly H.B. 1405 comes primarily from additional fines amendments were added. (One of the amend- on speeding violations. The fines start at $10 and ments removed the age restriction.) The bill was then pulled by the Speaker before debate could be heard. The session ended without the bill being passed. The Massachusetts Chapter is committed States that prohibit insurers to passing this type of legislation in 2009. from denying coverage Colorado (2006), Connecticut (2006), District of Repeal of the UPPL Columbia (2007), Illinois (2007), Indiana (2007), Iowa, Maryland, New York (2008), Nevada, North UPPL is the state law that allows health insur- Carolina, Oregon (2007), Rhode Island, South Da- ers to deny reimbursement for services provided kota, and Washington State to patients for injuries incurred when an accident is a result of “the insured’s being intoxicated or States that never enacted UPPL under the influence of any narcotic.”4 (However, courts have ruled that insurance com- California had passed UPPL repeal legislation panies can use alcohol/drug exclusions in states for the last several years, only to have it vetoed by Gov. Arnold Schwarzenegger (R). In 2007, that are silent on Alcohol Exclusion Laws) UPPL repeal was included in A.B. 1461, a bill to Massachusetts, Michigan, Minnesota, New Mexico, create a pilot project regarding methamphetamine New Hampshire, Oklahoma, Utah, Vermont (re- intervention. In 2008, the bill was amended; the pealed the explicit law but never enacted prohibi- pilot project was stricken, leaving only the UPPL tions), and Wisconsin repeal. As of press time, the bill has been agreed upon by both chambers and will be presented to the Governor. 28

VOLUME 93, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS After several years of trying, New York State tional registration system used to confirm that also passed the UPPL repeal; unlike standard physicians and health care practitioners are ap- UPPL repeal legislation, however, A.B. 10000 only propriately licensed and in good standing in their applies to automobile insurance policies, which, in respective states, with their licenses recognized New York, is the primary payor after a crash. in affected states for the duration of emergency Tennessee, which does not prohibit these exclu- declarations. sions, saw a pair of bills (H.B. 2875/S.B. 3043) The term “health care provider” is defined very introduced in 2008 that would require health care broadly in this legislation and includes nurses, providers to notify law enforcement officers at the pharmacists, morticians, and veterinarians, which hospital if results of tests performed on the driver helps to create a large and diverse coalition of of a vehicle involved in a collision indicate that the supporters. driver had a .08 percent blood alcohol content or In 2007, the model bill was modified to include li- was under the influence of drugs. Neither of these ability protections. The model legislation includes bills had any real momentum and both died upon two options from which a sponsor may choose: adjournment; this type of legislation is new to the ACS, and the organization will continue to moni- In Alternative ‘A,’ a volunteer health practitio- tor the situation. ner is not liable…unless the conduct in question rises to the level of willful misconduct, or wanton, The UEVHPA grossly negligent, reckless, or criminal conduct…. Alternative ‘B’ utilizes the same basic exclusions, A new priority for State Affairs is the UEVHPA, but caps the compensation a volunteer can receive which was created in 2006 and modified in 2007 by in connection with the emergency (not including the Uniform Law Commission; six states have al- reimbursement of reasonable expenses) at $500 ready adopted this legislation: Colorado, Indiana, per year, and does not include the limitation on Kentucky, New Mexico, Tennessee, and Utah. vicarious liability.5 The Uniform Law Commission (formerly known as the National Conference of Commissioners on A third, “unofficial” option is to simply refer to Uniform State Laws) is a nonpartisan organiza- the state’s current Good Samaritan Laws. tion devoted since 1892 to working toward the In 2008, a dozen states introduced UEVHPA: development and enactment of uniform state Hawaii, Illinois, Indiana, Louisiana, Maryland, laws. The purpose of the UEVHPA is to allow state Minnesota, Mississippi, New Mexico, Oklahoma, governments to give reciprocity to other states’ Pennsylvania, Utah, and Vermont. Only Indiana, licensees who are emergency services providers New Mexico, and Utah passed the legislation. This so that covered individuals may provide services legislation is expected to be introduced in at least without meeting the licensing requirements of a dozen states in 2009. state experiencing a disaster. It recognizes a na- Scope of practice *The definition of the foot as originally proposed by the Texas State Board of Podiatric Medical Examiners: The physician community scored a big win in The foot is the tibia and fibula in their articulation Texas in 2008—the Texas Third Court of Appeals with the talus, and all bones to the toes, inclusive of ruled that the Texas State Board of Podiatric all soft tissues (muscles, nerves, vascular structures, Medical Examiners went outside its scope when tendons, ligaments and any other anatomical structures) it adopted a rule that expanded the definition of that insert into the tibia and fibula in their articulation with the talus and all bones to the toes. the foot to include the bones in the ankle.* The court made this decision, in part, because in the Texas Orthopaedic Association, Texas Medical Association expanded definition, and Andrew M. Kant, MD v. Texas State Board of Podiatric Medical Examiners, Texas Podiatric Medical Associaton, and Bruce A. Scuddy, DPM. Source: http:// ...many of the soft tissues included in this definition www.3rdcoa.courts.state.tx.us/opinions/HTMLOpinion. are not part of the foot or even the ankle. For ex- asp?OpinionID=16860. ample, various nerves ending in the foot—including 29

NOVEMBER 2008 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS the tibial nerve, the peroneal nerve, and the sural The Georgia House passed the bill 138–17, and nerve—run along significant portions of the leg the Senate quickly followed suit with a 44–7 before reaching a termination point in the foot.... vote on April 5, the last day of the state’s 2008 Similarly, several veins and arteries—including the legislative session. Gov. Sonny Perdue (R) signed saphenous vein and the tibial artery and vein—also the bill into law on April 9. (For more informa- end in the foot after having traversed significant tion about this legislation, go to http://www.legis. portions of the leg.... In fact, one of the nerves and ga.gov/legis/2007_08/sum/sb433.htm.) one of the veins previously mentioned run along the entire length of the leg.5 A final reminder

In 2007, the College formally joined the Steer- The State Affairs staff in the Division of Ad- ing Committee of the American Medical Asso- vocacy and Health Policy is always available to ciation Scope of Practice Partnership (SOPP). surgeons and ACS chapters when a legislative In 2008, the SOPP awarded several grants to or regulatory issue arises. For more information both state medical societies and state specialty on state legislative issues or to discuss a particu- societies to fight scope battles in their states. lar impending state bill or regulation, contact In each state where grants have been awarded Melinda Baker at 312/202-5363 or mbaker@ there have been physician victories. facs.org. 

Provider taxes References

The Maryland medical community came 1. South Dakota Legislature, Legislative Research Council. Available at: http://legis.state.sd.us/ together on March 12, to testify in opposition sessions/2008/Bills/SB200ENR.htm. Accessed Au- to H.B. 614. This bill would have imposed a 6 gust 28, 2008. percent sales tax on certain elective cosmetic 2. Kentucky Legislature, Kentucky Legislative Re- procedures performed in the state unless they search Commission. Available at: http://www.lrc. ky.gov/record/08RS/HB371/bill.doc. Accessed August are determined to be medically necessary. As 28, 2008. introduced, the procedures included gastric by- 3. Uniform Accident and Sickness Policy Provision pass surgery, breast reduction or augmentation, Model Law (UPPL) adopted by the National Asso- teeth whitening, laser eye surgery, rhinoplasty, ciation of Insurance Commissioners in 1947. 1950 facelift, liposuction, laser hair removal, tattoo- Proceedings of the National Association of Insurance Commissioners, 81st Annual Session, June 13, 1950; ing, or body piercing. Quebec, Canada. Kansas City, MO: National Associa- Surgeons at the hearing spoke about the fail- tion of Insurance Commissioners, 1950-1952, 161, ure of New Jersey’s cosmetic surgery tax to raise 950. 1950 NAIC Proc. 398 projected revenues for that state and emphasized 4. Uniform Law Commission. Available at: http://www. uevhpa.org/DesktopDefault.aspx?tabindex=1& the complexity of determining medical necessity tabid=53. Accessed August 28, 2008. for many cosmetic procedures. After much testi- 5. Frank H. Netter, MD, Atlas of Human Anatomy mony, the bill was held in committee. 482, 483, 485, 504 (2nd ed. 1997) as cited by: Texas Orthopaedic Association, Texas Medical Associa- tion and Andrew M Kant, MD v. Texas State Board Certificate of Need of Podiatric Medical Examiners, Texas Podiatric Medical Associaton, and Bruce A. Scuddy, DPM. In April, after years of grassroots advocacy on the legislative, regulatory, and judicial fronts, Georgia surgeons who fought to have general sur- gery defined as a single specialty finally achieved victory in the General Assembly. A certificate of need (CON) reform bill, S.B. 433, contained language that recognizes general surgery as a single specialty eligible for the exemption from the CON process for ambulatory surgery centers. 30

VOLUME 93, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Socioeconomic tips

ACS Coding Hotline: Cholecystectomy questions by Linda Barney, MD, FACS; Albert Bothe, Jr., MD, FACS; and Debra Mariani, CPC, Practice Affairs Associate, Division of Advocacy and Health Policy

his column lists some frequently asked questions regarding Current Procedural Around the corner TTerminology (CPT)* recently posed to The 2009 ACS-sponsored Coding Workshops the ACS Coding Hotline and the responses. As schedule will be published soon on our Web site at a benefit of membership in the College, ACS www.facs.org/ahp/workshops. members and their staff may consult the hotline 10 times annually without charge. If your office November has coding questions, contact the Coding Hotline • Be sure to look for practice management tele- at 800/227-7911 between 8:00 am and 6:00 pm conferences from Economedix. To register, go to Mountain Time, holidays excluded. our Web site at http://www.facs.org/ahp/workshops/ teleconferences.html. The surgeon performed an open cholecys- • CPT Coding & 2009 Update for Doctors and tectomy with cholangiography. When the Staff will convene November 12. Building a Bottom- Line Budget for 2009 will be held November 26. procedure was done, there was a fistula into the colon, so he repaired the colon. We are coding this surgery with code 47605, Cholecystectomy; with cholangi- caval nodes (list separately in addition to ography, and code 44604, Suture of large code for primary procedure)? intestine (colorrhaphy) for perforated ulcer, diverticulum, wound, injury or Code for the cholecystectomy using 47562, rupture (single or multiple perforations); Laparoscopy, surgical; cholecystectomy. There is without colostomy. The diagnosis for the no extra coding for removal of the common bile cholecystectomy was stones. Should the duct lymph node. surgeon give the diagnosis of fistula in gallbladder? The procedures dictated in the operative note are cholecystectomy with choledocho- fThe use o the two CPT codes is correct. The enterostomy and a gastrojejunostomy. In International Classification of Diseases, Ninth the note, the surgeon stated that the gas- Revision (ICD-9), diagnosis for the gallbladder trojejunostomy was performed 30 cm away problem is 574.00. The fistula should have a from where the choledochoenterostomy was diagnosis of 575.5. completed. Which codes should be used?

The surgeon performed a laparoscopic cho- The codes for this surgery would be 47612, lecystectomy with removal of a common Cholecystectomy with exploration of common bile duct lymph node. Do I also code 38747, duct; with choledochoenterostomy, and 43820, Abdominal lymphadenectomy, regional, in- Gastrojejunostomy; without vagotomy. cluding celiac, gastric, portal, peripancre- atic, with or without para-aortic and vena The surgeon planned a laparoscopic cho- *All specific references to CPT (Current Procedural Terminology) lecystectomy but encountered problems terminology and phraseology are © 2007 American Medical that necessitated switching to an open Association. All rights reserved. procedure. The surgeon also did a partial 31

NOVEMBER 2008 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS should report the open procedure code only. You PEG tube coding tips can use the code V64.41, Laparoscopic surgical • If the surgeon replaces the percutaneous procedure converted to open procedure, to show endoscopic gastrostomy (PEG) tube because of the conversion to open procedure. clogging or other factors, code 43760, Change of gastrostomy tube, if there is no image guidance. The patient underwent a laparoscopic • If the surgeon performs a replacement of cholecystectomy, but the surgeon also did gastrostomy or cecostomy (or other colonic) tube, an open cholangiogram. How would I code percutaneous, under fluoroscopic guidance includ- these two procedures? ing contrast injections(s), image documentation and report, use 49450. The cholecystectomy code that includes the • If the surgeon encounters a problem replacing cholangiogram is 47563. Code the laparoscopic the PEG tube and uses endoscopy to determine the problem and assist in the tube removal, it would code, 47563, Laparoscopy, surgical; cholecystec- be appropriate to code a diagnostic endoscopy code tomy with cholangiography, with the –22 modi- and 43760, Change of gastrostomy tube. fier (Increased Procedural Services) to indicate • You cannot report a separate code for simple that the cholangiography was done as an open PEG tube removal. Use the appropriate evalu- procedure and include a detailed description of ation and management codes. Removing a PEG the situation in the operative note. tube does not qualify as foreign body removal, so 43247, Upper gastrointestinal endoscopy including The patient had a laparoscopic cholecystec- esophagus, stomach, and either the duodenum and/ tomy, 47563, and within the global period or jejunum as appropriate; with removal of foreign (90 days) of this procedure was taken back body would not be appropriate. Only use code 43247 if a scope is used to retrieve a broken portion of a to the operating room for a Whipple proce- PEG tube that remains in the stomach. dure, 48150. The surgeon is also coding the +44015, Tube or needle catheter jejunostomy for enteral alimentation, intraoperative, colectomy. We are coding 44144, Colectomy, any method (list separately in addition to partial; with resection, with colostomy or primary procedure), and placed the –79 ileostomy and creation of mucofistula, and modifier on both of these codes. Is this the 47600, Cholecystectomy, but the surgeon also correct coding? wants to know if 49320, Laparoscopy, abdo- men, peritoneum, and omentum, diagnostic, Coding the 48150, Pancreatectomy, proximal with or without collection of specimen(s) by subtotal with total duodenectomy, partial gastrec- brushing or washing (separate procedure), tomy, choledochoenterostomy and gastrojejunos- for the laparoscopic portion of the proce- tomy (Whipple-type procedure); with pancreato- dure can be coded. jejunostomy, with the –79 modifier (Unrelated procedure or service by the same physician during You generally will code procedures with the the postoperative period) is correct. Add-on codes highest relative value units first.† Use 44144, are exempt from modifiers so the –79 modifier is Colectomy, partial; with resection, with colostomy not necessary with +44015. Guidelines for add- or ileostomy and creation of mucofistula. The on codes can be found in the Introduction of the relevant ICD-9 diagnosis should also be listed Professional Edition of the CPT.  on the first line of the claim form. Then code 47600, Cholecystectomy. Remember, you should Dr. Barney is associate professor and associate program not report both the open and laparoscopic codes director for general surgery, department of surgery, Wright State University Boonshoft School of Medicine, for the same procedure. If the surgeon converts a and member, Wright State Surgeons, Miami Valley Hos- laparoscopic procedure to an open procedure, you pital, Dayton, OH.

†Medicare Correct Coding Guide. Salt Lake City, UT: Ingenix; Dr. Bothe is chief quality officer, Geisinger Health 2007 (ISBN 1-978-56337-949-9). System, Danville, PA. 32

VOLUME 93, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS College news

Dr. Cameron installed as 89th ACS President

John L. Cameron, MD, FACS, as a member of the Executive a general and thoracic surgeon Committee (2006–2007), Board who specializes in treatment of Regents Honors Committee of alimentary diseases, was (2005–present), Investment installed as the 89th President Subcommittee of the Finance of the American College of Committee (2002–present), Surgeons during Convocation and Finance Committee (1998 ceremonies that preceded the to present). In addition, Dr. official opening of the College’s Cameron served as a senior 94th annual Clinical Congress member of the College’s Com- in San Francisco, CA, in Octo- mittee on Video-Based Educa- ber. Dr. Cameron is the Alfred tion (1980–1990). Blalock Distinguished Service In addition to his service to Professor of Surgery at The the College, Dr. Cameron has Dr. Cameron Johns Hopkins University held many leadership positions School of Medicine, Baltimore, in organized surgery. He was MD. president of the American Sur- Dr. Cameron received a bach- gical Association (2000–2001), His research interests have elor of arts degree from Har- the Halsted Society (1997– included randomized clinical vard University, Cambridge, 1998), the Southern Surgical trials and clinical outcomes MA (1958), and earned a medi- Association (1995–1996), the in pancreas surgery as well as cal degree from Johns Hopkins Society of Surgical Chairs basic laboratory research of University School of Medicine (1994–1996), the Society for pancreatic diseases, for which (1962). He served a surgical Surgery of the Alimentary he has received grant support internship at Johns Hopkins Tract (1991–1992), the Society from the National Institutes (1962–1963) before he began of Clinical Surgery (1990– of Health. service in the U.S. Army as a 1991), and the Baltimore Acad- Throughout his distinguished research surgeon in the depart- emy of Surgery (1985–1986). career, Dr. Cameron has exem- ment of surgical metabolism He also was a director of the plified a strong commitment to at Walter Reed Army Institute American Board of Surgery the dissemination of surgical of Research (1963–1965). He (1986–1992). knowledge. He is the author returned to Johns Hopkins in Trained in both general and of several internationally rec- 1965, where he completed a thoracic surgery, Dr. Cameron ognized surgical textbooks, surgical residency (1965–1970) has devoted his professional including Atlas of Surgery I and then a clinical and research life to several significant clini- and II, Atlas of Biliary Tract fellowship (1970–1971) at the cal and research endeavors Surgery, Atlas of Clinical On- Johns Hopkins Hospital. in alimentary tract diseases, cology, and nine editions of A Fellow of the American Col- specifically in pancreatic can- Current Surgical Therapy, and lege of Surgeons since 1975, Dr. cer. A leader in alimentary the coauthor of Evidence Based Cameron has been actively in- tract surgery, he has operated Surgery, written with Toby A. volved in the governance of the on more patients with pan- Gordon, ScD. Moreover, Dr. College, including serving as creatic cancer and done more Cameron has served as the au- Treasurer from 1998 to 2007. Whipple resections than any thor or coauthor of 99 chapters Dr. Cameron has also served other surgeon in the world. in surgical textbooks and 384 33

NOVEMBER 2008 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS clinical and research articles Surgeons, Surgery, Journal Advances in Surgery. published in the medical lit- of Hepato-Biliary-Pancreatic Dr. Cameron currently re- erature. He has also contrib- Surgery, Digestive Diseases sides in Ruxton, MD, with his uted to the surgical profession and Sciences, Asian Journal wife Doris Mae. They have two through his work as a member of Surgery, and The American daughters, Heather and Shan- of the editorial boards of the Surgeon. He currently is the non, and two sons, Duncan and following journals: Journal editor-in-chief of the Journal Andrew. of the American College of of Gastrointestinal Surgery and

Honorary Fellowships presented to five prominent surgeons

Honorary Fellowship in the immediate past-president, Diaz, MD, FACS, Southfield, American College of Surgeons Royal College of Surgeons of MI; Carlos A. Pellegrini, MD, was awarded to the follow- Ireland (Dublin); lecturer and FACS, Seattle, WA; Tom R. ing five prominent surgeons professor of surgery, University DeMeester, MD, FACS, Los An- from Belgium, Brazil, Ireland, College, Cork; director, Cork geles, CA; George F. Sheldon, United Kingdom, and Australia Cancer Research Centre, Cork; MD, FACS, FRCSEd(Hon), during Convocation ceremonies and consultant surgeon, Mercy FRCSEng(Hon), Chapel Hill, at this year’s Clinical Congress University Hospital, Cork, Ire- NC; and L. D. Britt, MD, FACS, in San Francisco, CA: land. Norfolk, VA. • Jacques Brotchi, MD, • Bernard F. Ribeiro, This year, 1,189 surgeons PhD. Dr. Brotchi is president CBE, FRCSEng, FRCPEng. from around the world were of the World Federation of M r. R i b e i r o i s a p a s t - admitted into Fellowship dur- Neurosurgical Societies and president of the Royal College ing the College’s Convocation emeritus professor and honor- of Surgeons of England; senior ceremonies. ary chairman, department of lecturer, Middlesex Hospital, Sir Rickman Godlee, Presi- neurosurgery, Erasme Hos- London; and director, under- dent of the Royal College of pital, University of Brussels, graduate teaching for surgery, Surgeons of England, was Brussels, Belgium. University College, London, awarded the first Honorary Fel- • Joaquim Gama- United Kingdom. lowship in the College during Rodrigues, MD, FACS. Dr. • Russell W. Strong, MB, the College’s first Convocation Gama-Rodrigues is director of BCh, FACS, FRCSEdin(Hon), in 1913. Since then, 413 inter- gastrointestinal surgery and F R A C S , F R C S E n g , nationally prominent surgeons, gastroenterology, Hospital FRACDS. Dr. Strong is emeri- including the five chosen this Alemáo Oswaldo Cruz and tus professor, surgical special- year, have been named Honor- Hospital da Beneficência Por- ties, Princess Alexandria Hos- ary Fellows of the American tuguesa, Sao Paulo, Brazil. pital, Brisbane, Australia. College of Surgeons. • Gerald C. O’Sullivan, Presenting the Honorary Following are the citations MB, BCh, FACS, FRCSGlas, Fellowships on behalf of the presented during the Convoca- FRCSI. Dr. O’Sullivan is the College were Fernando G. tion. 34

VOLUME 93, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Citation for Prof. Jacques Brotchi by Fernando G. Diaz, MD, PhD

Mr. President, it is my honor est on the use of positron emis- to introduce Prof. Jacques sion tomography (PET) scan Brotchi of Brussels, Belgium, combined with neurosurgery— for Honorary Fellowship in PET-guided stereotactic biop- the American College of Sur- sies; PET-guided neuronavi- geons. gation; and, thereafter, PET- Professor Brotchi was born in guided gamma knife treat- Liège in 1942 during the Second ment. He has also equipped World War. After graduating in his department with magnetic medicine (MD) from the State resonance imaging and, before University of Liège in 1967, retiring, with a magnetoen- Professor Brotchi completed cephalography. his training in neurosurgery Deeply involved in educa- with Prof. J. Bonnal in the tional programs of the World same university, where he also Federation of Neurosurgical Professor Brotchi invested in basic research in Societies (WFNS) since 1991, the Neuroanatomy Laboratory he is currently president of (under Prof. M.A. Gerebtzoff). the WFNS. He has held that Then, in 1982, he moved from position since 2005 and will of the Merit Order of Spain. Liège to Brussels, where he complete it in 2009. In 1988, King Baudouin created the department of neu- In 1998, his department was of Belgium ennobled him as rosurgery at Erasme University distinguished by the World knight for his contributions to Hospital. Health Organization (WHO) neurosurgery and Belgium. In Head of the department since and nominated “First World- 2007, King Albert II of Belgium 1982, full professor and chair- wide WHO Collaborating Cen- upgraded him to the rank of man at the Free University of ter for Research and Training baron. Brussels (ULB) since 1984, he in Neurosurgery.” In 2000, Finally, since 2004, he has was also director of the ULB he received one of the most been senator of the Royal King- laboratory of experimental neu- prestigious Belgian medical dom of Belgium and was re- rosurgery until September 1 prizes—Scientific Prize, Joseph elected in June 2007. His fields of this year, when he became Maisin-Clinical Biomedical of interest are health, medical honorary chairman and emeri- Sciences—within the scientific research, and bioethics. He also tus professor. He continues quinquennial prizes of the Na- has created in the Belgium Sen- his surgical activity as a tional Research Foundation of ate a Brainstorming Group for consultant-neurosurgeon in the the period 1996–2000. Peace in the Middle East that department. A member of the Royal Acad- he is chairing. Professor Brotchi has pub- emy of Medicine of Belgium Jacques Brotchi and his wife lished more than 350 papers and of the French Academy of Rachel have one daughter, Na- in international journals, with Surgery, Professor Brotchi has thalie, and two grandchildren, special emphasis on meningio- been awarded Commandeur Nina and Dylan. mas and surgical approaches of de l’Ordre de Leopold of Bel- pineal lesions and almost in- gium, Chevalier de la Légion traspinal cord tumors. He has d’Honneur of France, Chevalier stimulated many works in his of Danneborg Order of Den- department with a special inter- mark, and Great Commandeur 35

NOVEMBER 2008 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Citation for Prof. Joaquim Gama-Rodrigues by Carlos A. Pellegrini, MD, FACS

Mr. President, ladies, and pital Alemão Oswaldo Cruz, gentlemen, thank you for the São Paulo. His research focus privilege of introducing Prof. has been the oncogenesis and Joaquim Gama-Rodrigues of oncogenomics and treatment São Paulo, Brazil, for Honor- of gastric and colonic cancer. ary Fellowship in the American Gama is the principal investi- College of Surgeons. gator of the Brazilian Clinical Gama, as he is known among Cancer Genome Project, which his friends and colleagues, was was initiated in 2000. The proj- born in Cruzeiro, São Paulo, ect includes seven collaborat- Brazil, and completed his medi- ing institutions and hospitals cal studies at the prestigious throughout the state of São School of Medicine of the Uni- Paulo and the Ludwig Institute versity of São Paulo. It was dur- for Cancer Research and has ing his medical school training developed the largest national Professor Gama-Rodrigues that he met Renato Locchi—a cancer genome database. teacher known for his inspir- Professor Gama-Rodrigues’ ing intellectual character and fascination for molecular biolo- discipline—who introduced gy and his understanding of the been honored by graduating him to surgical anatomy and genetic mechanisms involved in classes as the Teacher of the awakened in young Gama a the carcinogenesis of tumors Year and has actively partici- desire to become a surgeon. of the alimentary tract led him pated in formal mentoring of Having emulated the discipline to search for new alternatives postgraduate students and of his teacher and using his own for screening, diagnosing, stag- fellows in the area of gastroin- drive, he was quickly singled ing, and treating cancer. His testinal cancer, many of whom out by some famous surgeons ability to convince the medical now populate the hospitals of of the time, such as Arrigo Raia community, hospital adminis- Brazil. Because he embraces and Correa Neto, who adopted tration, and fundraisers of the change and innovation easily, this young student and got importance of this effort led to he was instrumental in the him into a surgical residency the formation of a state-of-the- adoption of laparoscopy—and, at the Hospital Das Clinicas art tumor tissue bank. more recently, robotics—in his of the University of São Paulo. Gama has a particular pas- country and was recognized by After he completed his training, sion for education and educa- the Brazilian Society of Lapa- Gama joined the faculty of his tional systems. As a member roscopic Surgery with its Medal school, where he quickly moved of many local, regional, and na- of Honor. through the ranks to become a tional committees and through During his long career as a full professor of surgery. the role he played in the Post- surgeon, he has been particu- Professor Gama-Rodrigues graduate Commission in Brazil, larly concerned about the fate focused his career on surgery he has been able to set in place and lack of access to care of the of the alimentary tract, with modern systems of education, poor and has devoted countless a particular interest in cancer consolidating graduate and hours to working with groups of the digestive tract, even- postgraduate education and in safety-net hospitals to im- tually becoming director of emphasizing the need for life- prove access to care for these gastrointestinal surgery and long learning and teamwork. As individuals. As his interest in gastroenterology at the Hos- an educator, he has repeatedly the social aspects of medicine 36

VOLUME 93, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS and surgery grew, he took ad- das Palmeiras, has been so suc- great honor that I present ditional courses to become a cessful that it is now ready for to you Prof. Joaquim Gama- specialist in tropical medicine, implementation throughout Rodrigues—a great surgeon- a discipline that deals with São Paulo, one of the world’s scientist, a respected teacher, diseases prevalent in Brazil largest metropolises with an a community leader, and a and thus directly affecting his estimated population of 20 mil- formidable human being—for community. Gama’s interest in lion. This interest in the health Honorary Fellowship in the public health led him to develop of his community led him to American College of Surgeons. and participate extensively in join the Curator Council of the And may I add, sir, that this public health campaigns like Oncological Center Foundation is a historic moment for our anti-smoking and early detec- in São Paulo. Today he holds institution, as Gama is married tion and prevention of gastro- the position of chairman of the to Angelita Habr-Gama, who intestinal cancer programs. council, which is a state agency became an Honorary Fellow a One of those programs, the for policies in prevention, early few years ago. Thus, this is the Colorectal Cancer Screening detection, and education for first wife/husband team of Hon- program, first piloted in the cancer management. orary Fellows of the American small community of Santa Cruz Mr. President, it is with College of Surgeons.

Citation for Prof. Gerald C. O’Sullivan by Tom R. DeMeester, MD, FACS

Mr. President, it is my privi- At the University of Chicago, lege and honor to present to you the late Dr. David Skinner and the distinguished Irish surgeon I had the distinct pleasure of Gerald Christopher O’Sullivan, having Dr. O’Sullivan work currently professor of surgery with us for two years as a re- at University College Cork, search associate, from 1979 director-in-chief of the Cork to 1981. During that time, Dr. Cancer Research Center, and O’Sullivan’s creativity as an consultant surgeon at Mercy investigator and his genetic University Hospital, University capacity as a storyteller became College Cork, Cork, Ireland. known and appreciated by all. Professor O’Sullivan was Gerry impressed on us the Irish born in Cork in 1946 where he principle that “no good story received his undergraduate and should remain untold for the graduate medical education. He lack of a few facts.” The Chicago Professor O’Sullivan was elected into fellowship of experience accounted for eight the Royal College of Surgeons of his first 15 papers—only the of Ireland in 1974 and became beginning of his current volu- its president in 2006. In 1975, minous bibliography. boasts of activities that focus he traveled to Edmonton, AB, It comes as no surprise that on the gene therapy of can- where he received his master of Professor O’Sullivan became cer, creative ways to facilitate science degree in experimental the founder and director of the drug delivery to solid tumors, medicine from the University of Cork Cancer Research Center, immune control of cancer, pre- Alberta. In 1999, he became a which currently has a staff of vention of colon cancer, iden- Fellow of the American College 32 people. The center has been tification and therapy of bone of Surgeons. fully active for nine years and marrow micrometastasis, and 37

NOVEMBER 2008 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS the biological behavior of upper land, Professor O’Sullivan ing support of his wife, Breda, gastrointestinal cancers. established a surgical train- for 36 years. They have three Professor O’Sullivan’s clini- ing program in 10 countries children—Orla, Gearoid, and cal interests, as expected, are in in East and Central Africa Eoghan. It is difficult to fathom surgical oncology with a focus through collaboration with that with all he has done he on upper gastrointestinal sur- the College of Surgeons of would have spare time, but he gery for benign and malignant East, Central, and Southern does find and cherish time to disease. Through his research, Africa. The development of an read extensively and practice lectures, writing, and practice, intercollegiate structure has armchair philosophy with ever- patients and surgeons through- provided high-quality surgical present guests. out the world have benefited training in those countries. Mr. President, Prof. Ger- from his knowledge, expertise, He also developed a strategy ald O’Sullivan is known and and compassion. For his work, to enable surgical research loved by many surgeons and he has been widely recognized by all surgeons in Ireland ir- physicians. His investigative nationally and internationally respective of their hospital studies, creative thinking, and as an outstanding communica- type or surgical specialty. This provocative lectures have had a tor and has delivered more than strategy involved creation of a profound impact on Irish, Euro- 11 named lectures. Professor network to facilitate collabora- pean, and American surgery. He O’Sullivan is president-elect tion, create an opportunity for has achieved his objectives with of the European Surgical As- intercalated doctoral programs indefatigable energy, innova- sociation, and he has served for suitable candidates, and tive thinking, and collaboration with distinction as president of organize a structure to provide, with colleagues. He is a most the Royal College of Surgeons manage, and coordinate generic worthy recipient of Honorary in Ireland and the Irish Society support. Fellowship in the American of Gastroenterology. During his outstanding ca- College of Surgeons. While president of the Royal reer, Professor O’Sullivan has College of Surgeons in Ire- been fortunate to have the lov-

Citation for Mr. Bernard Ribeiro by George F. Sheldon, MD, FACS, FRCSEd(Hon), FRCSEng(Hon)

Mr. President, it is my honor Surgeons in 1913, Sir Rickman to present Mr. Bernard Ribeiro Godlee. of Hampshire, England, for Mr. Ribeiro is of British/ Honorary Fellowship in the Ghanaian nationality. His edu- American College of Surgeons. cation was at the Dean Close Mr. Ribeiro is an accom- School in Cheltenham (1957– plished international surgeon 1962) and Middlesex Hospital and is the immediate past- Medical School (1962–1967). president of the Royal College After concluding training, of Surgeons of England. He he was appointed consultant follows many previous Royal surgeon to Basildon Hospital, College presidents in becom- Essex, where he introduced lap- ing an Honorary Fellow of this aroscopic surgery to the Trust College, including our first and established an advanced Honorary Fellow at the found- laparoscopic unit that has per- Mr. Ribeiro ing of the American College of formed more than 1,000 chole- 38

VOLUME 93, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS cystectomies. His involvement the first completed stage is the tive (EWTD), the equivalent of in undergraduate and graduate Wolfson Surgical Skills Labora- the Accreditation Council on education was instrumental in tory that has bench top clinical Graduate Education’s 80 hour forging links with University skills areas and minimally in- workweek requirement. In College London, which contrib- vasive surgery simulation tools. 2008, he joined the leadership uted to the Trust achieving He also initiated an independent of the American College of Sur- university status in 2002. external review of the structure geons in presenting testimony Mr. Ribeiro’s leadership skills and activities of the Raven De- on work hours to the Institute were recognized early in his partment of Education. of Medicine of the National career. He became secretary Mr. Ribeiro’s presidency Academy of Sciences’ Optimiz- and then president of the As- came as the National Health ing Graduate Medical Trainee sociation of Surgeons of Great Service (NHS) was undergoing (Resident) Hours and Work Britain and Ireland (ASGBI) in extensive reorganization, which Schedules to Improve Patient 1991 through 2000. He repre- included changes with negative Safety panel. He described the sented the ASGBI on the Senate implications for physicians and impact on surgical education of Surgery, an organization of surgeons in training. The sea in England and elsewhere in the four surgical colleges and change in the format of British the European Union under the nine specialist associations in education occurred within the EWTD. The American College Great Britain and Ireland. He context of the NHS program of Surgeons has been a ben- was elected to the Council of Modernising Medical Careers eficiary of his participation in the Royal College of Surgeons (MMC).f Part o the reorgani- postgraduate programs at the of England in 1998, and he zation included the Medical Clinical Congress. received a fellowship from the Training Application Service Bernie, as he is known, is a Royal College of Surgeons of as a cornerstone of the MMC devoted family man. He and his Edinburgh ad hominem in initiative. Unfortunately, the wife, Liz, have one son and three 2000. In 2004, he was appointed implementation of the program daughters, two of whom are Commander of the Order of the produced many problems, which twins. His son Richard and his British Empire for services to included insufficient numbers of wife Joanne have given Bernie medicine. advanced training positions. Mr. and Liz their first grandchild. The crowning organizational Ribeiro led the United Kingdom Bernie and Liz have moved achievement of Mr. Ribeiro’s ca- in working constructively but recently from Essex to Hamp- reer was election in July 2005 to firmly to ensure that patient shire, where Liz is overseeing a three-year term as president care would be unaffected and extensive building and renova- of The Royal College of Sur- that the flawed recruitment tion. They have a stretch of geons of England. Continuing process would not mar the the River Itchen, where Bernie the work of his predecessors, careers of a generation of com- enjoys his passion for fishing. he presided over the expansion mitted trainees. He successfully Another member of the family of the Royal College’s leading secured a significant tempo- is a black dog named Meg that historical role in surgical educa- rary expansion of ST3 surgical Bernie claims is a good retriever, tion. The facilities of the Royal training posts. While so doing, but in reality is a pet. College of Surgeons have been he shared his experience with As president of The Royal Col- expanded, the Hunterian Mu- the international community. lege of Surgeons of England, Mr. seum has been remodeled, the The experience of dealing with Bernie Ribeiro will be remem- education and training facili- a shortage of funded training bered as the trainees’ advocate, ties have been upgraded, and a positions in surgery is also oc- much as his close friend, Claude policy unit has been established curring in the U.S. Organ, MD, FACS (deceased), is at the headquarters at Lincoln’s Mr. Ribeiro has led the inter- remembered as the residents’ Inn Fields. His presidency saw national community in address- president of the American Col- the commencement of the suc- ing the problems raised by the lege of Surgeons. cessful Eagle Project, for which European Working Time Direc- 39

NOVEMBER 2008 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Citation for Prof. Russell W. Strong by L. D. Britt, MD, FACS

Mr. President, it is my honor of the top liver surgeons in to present to you Prof. Russell the world. He has more than Walker Strong of Brisbane, 260 scientific publications Australia, for Honorary Fel- to his credit, including 14 lowship in the American Col- book chapters. His landmark lege of Surgeons. contributions to the medical Professor Strong was born literature have paved the way in Lismore, New South Wales. for the definitive management He is currently professor of of some of our most challenging surgery at the University of hepatic injuries and diseases. Queensland in Brisbane and He developed and pioneered director of surgery at the Prin- the “Brisbane technique” of cess Alexandra Hospital. Pro- reduced-size liver transplant fessor Strong completed his un- for children. Professor Strong dergraduate medical education performed the first successful Professor Strong at the University of London. living related liver transplant He remained in England for in the world in 1989, when his graduate medical training, a portion of a mother’s liver where he was the senior house was transplanted into her son; 1986 and was the recipient of surgeon at the Birmingham both are alive and well 19 years the Companion of the Distin- Accident Hospital, the surgi- later. He now has an impres- guished Order of St. Michael cal registrar at the Charing sive personal series, which is and St. George presented by Cross Hospital in London, and considered by many to be un- Her Majesty, Queen Elizabeth, the senior surgeon registrar paralleled with respect to both at Buckingham Palace. He also at the Whittington Hospital, numbers and outcomes. received Australia’s highest London. It is a certainty that Profes- civilian honor, the Companion Professor Strong moved sor Strong’s legacy will con- of the Order of Australia. south to Brisbane to launch tinue for generations, for he Professor Strong, the con- his academic career. Starting has been very active in training summate clinician/surgeon, as a surgical supervisor at the young surgeons, particularly in educator, investigator, and Princess Alexandra Hospital, Southeast Asia. He has trained humanitarian, embodies all the his rapid ascent in academic more than 80 surgeons from laudable tenets of an honorary surgery was remarkable. Pro- overseas in hepatobiliary and fellowship. fessor Strong was selected to be liver transplant surgery. Many Mr. President, it is my dis- the James IV Travelling Fellow, of his fellows have returned to tinct privilege to present this which afforded him the op- Indonesia, Japan, Malaysia, world-renowned surgeon, Prof. portunity to have intellectual and several other countries Russell Strong, for Honorary exchange and share his techni- to become leaders in hepatic Fellowship in the American cal expertise with many of his surgery and liver transplanta- College of Surgeons. international colleagues. tion. The recipient of an almost In addition to his innumera- endless list of academic awards ble academic accolades, Profes- and honorary fellowships, Pro- sor Strong is a highly decorated fessor Strong is acknowledged civilian. He was honored as the by experts in the field as one Queenslander of the Year in 40

VOLUME 93, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS EXAMINE THE ETHICAL UNDERPINNINGS OF THE ISSUES YOU FACE EVERY DAY

A case-based educational resource for surgeons at all stages of their careers, ETHICAL ISSUES IN CLINICAL SURGERY has all the components needed to help surgeons and residents examine the ethical underpinnings of clinical practice and address the ethical issues they face every day caring for their patients

Ethical Issues in Clinical Surgery was developed by the Committee on Ethics of the American College of Surgeons.

TOPICS • Framework for considering ethical issues in clinical surgery • Competition of interests • Truth telling and the surgeon-patient relationship • Confi dentiality • Professional obligations of surgeons • End-of-life issues • Substitute decision making

FEATURES OF EACH CHAPTER • Realistic surgery-based cases • Learning objectives • Questions for discussion • Analyses of cases and questions • Bioethics bottom line Ethical Issues in Clinical Surgery • Suggested readings Edited by Mary H. McGrath, MD, MPH, FACS • Glossary and additional resources

 ere are two versions of the book: one for course instructors and practicing surgeons that has CME credit available, and one for use with residents.

Pricing and ordering information can be found at http://www.facs.org/education/ethicalissuesinclinicalsurgery.html or by calling 312/202-5335.

AMERICAN COLLEGE OF SURGEONS • DIVISION OF EDUCATION

Ethical Issues ad (09-07) - Bull1 1 8/27/2008 9:59:32 AM In memoriam James C. Thompson, MD, FACS, 1928–2008 by Marshall J. Orloff, MD, FACS

James C. Thompson, MD, UTMB from 1951 to 1952. FACS, one of the leading sur- Toward the end of his in- gical scientists, educators, and ternship, he applied all over statesmen of the past half- the country for a residency in century, died at age 79 in his surgery and was turned down home in Galveston, TX, on by every institution except one, May 9, of prostate cancer. From and that was a fluke. The one 1970 to 1995, he was chairman program that accepted him of the department of surgery tentatively was at the Univer- at the University of Texas sity of Pennsylvania, headed Medical Branch (UTMB) in by I. S. Ravdin, MD, FACS, Galveston, where he also served who sent him a telegram that as the Ashbel Smith Professor read, “We are of course full, of Surgery and as professor in but any descendant of the fa- the department of physiology mous James E. Thompson of and biophysics. He is widely Galveston is welcome into my credited with building one of Dr. Thompson program. We will put you into the leading surgical scientific the Harrison Department of programs in the U.S. and with Surgical Research for a year, bringing about a sea change and then you can come into the throughout UTMB in education now Texas A&M University, clinic.” Jim Thompson didn’t and research. graduating with a bachelor have a clue as to who James E. Jim Thompson was not of science degree in just two Thompson was. In fact, James born with a silver spoon in years. In 1946, when he had E. Thompson was the founder his mouth. He grew up in the just turned 18 years, he entered many years earlier of the de- little cow town of Hebbronville medical school at UTMB. His partment of surgery at UTMB. in Jim Hogg County in south family was dirt-poor and even It was a clear case of mistaken Texas, population 3,000. His though the tuition was small, identity, which Jim Thompson father owned the town hard- he dropped out after his fresh- let pass, given his desperate ware store and died while on man year to earn sufficient circumstances. a hunting trip on horseback, funds to continue his medical After a year in the research when Jim was 14 years of age. education. He worked as a lab, Jim Thompson entered At best, the economic condition paid laboratory assistant to Dr. the clinical surgery residency of the family was modest. Jim Raymond Blount, professor of at Penn in 1953 and completed attended grade school and high anatomy, ultimately earning a residency in 1959. His training school in the single, little Heb- master’s degree in anatomy and was interrupted during the Ko- bronville public school. In 1944, endocrinology some years later. rean War by the “doctors draft,” when he had just turned age 16, He returned to medical school which resulted in a two-year he entered the Agricultural and at UTMB in 1948 and went on stint in the U.S. Army Medical Mechanical College of Texas, to serve a rotating internship at Corps in Germany, where he 42

VOLUME 93, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS achieved a modicum of fame in an academic surgical scientist. ous original and far-reaching Army circles. The Army classi- When he completed the surgi- studies undertaken by the fied him as a physician, general cal residency at Penn, he was Thompson laboratory focused duty, not a surgeon, and as- shunted off to the old Pennsyl- particularly on identification signed him to a small battalion vania Hospital, a Penn affili- and function of GI hormones clinic in Munich, where he took ate, to fend for himself. What in health and disease. The work daily sick call. In that capacity, he accomplished on his own at was made possible by research he saw soldier after soldier with the Pennsylvania Hospital from grants that Jim Thompson ob- the unfortunate socially trans- 1959 to 1963 was remarkable tained continuously for 41 years mitted disease of gonorrhea. and a tribute to his determina- from the NIH under highly The soldiers were very upset tion, tenacity, and ability. He competitive circumstances. The by the knowledge that they established a first-rate surgical laboratory and clinical research had gonorrhea, mainly because research laboratory on his own; accomplished by the Thompson they feared demotion or even obtained research grants from group resulted in 616 publica- expulsion from the Army. So, major agencies, including the tions in peer-reviewed journals, kindly, Lt. James Thompson, National Institutes of Health, 120 book chapters, and 588 MD, recorded in the medical on his own; published paper scientific abstracts in the 54 record a diagnosis of laryngitis after paper on gastrointestinal years from 1953 to 2007, a re- for each of these soldiers with physiology and disease on his markable record of productivity gonorrhea. Army medical head- own; and attracted the atten- that few academic surgeons quarters in Washington, DC, tion of leading gastrointestinal have equaled. was alarmed by the unusual (GI) scientists from the U.S. outbreak of laryngitis in Mu- and abroad, such as Lester Service to surgery nich and sent a team of senior Dragstedt, Roderick Gregory, and society infectious disease specialists and Morton Grossman. Jim Thompson’s record of and epidemiologists there to In 1963, knowing that his service to surgery and to society investigate. Needless to say, talent was not fully appreciated is unsurpassed. He was elected interrogation of Lieutenant and recognized at Penn, I was to the presidency of six major Thompson uncovered the truth able to recruit him to University national surgical organizations, of the matter, but the inspec- of California–Los Angeles Har- including the American College tors were so impressed by his bor General Hospital, where I of Surgeons, the American Sur- kindness and ingenuity that was chief of surgery. In 1967, gical Association, the South- they covered up the reported he succeeded me as professor ern Surgical Association, the epidemic of laryngitis. and chief of surgery. At Harbor Society for Surgery of the Ali- I first met Jim Thompson General Hospital, he continued mentary Tract, the Society of late at night in October 1952 his remarkably productive ca- Surgical Chairs, and the James in the research laboratories reer as an academic surgical IV Association of Surgeons. He of the Harrison Department scientist, so much so that in also served as president of the of Surgical Research at Penn. 1970, he was recruited by his Texas Surgical Society and the We liked each other from the alma mater, UTMB, to return South Texas Chapter of the start and we saw each other as professor and chair of sur- American College of Surgeons. regularly from then on, and gery for the next 25 years. He was heavily involved in throughout the next 56 years. service to the American College I recognized his enormous tal- Scientific contributions of Surgeons, having served as ent and engaging personality, The research laboratory that Chairman of the Committee but I do not believe the senior Jim Thompson established was for the Forum on Fundamental surgical faculty at Penn fully involved continuously in the in- Surgical Problems, a member appreciated his potential, a fact vestigation of basic and applied of the Board of Governors for that only served to increase his principles of GI physiology and six years, a member of the determination to succeed as endocrinology. The numer- Program Committee for 10 43

NOVEMBER 2008 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS years, Chairman of the Surgi- societies selected him as honor- The second Thompson at- cal Research and Education ary member, and the University tribute that deserves comment committee, and a member of of Beijing made him an “honor- was his unflagging support of the Scholarship Committee. ary professor for life.” In 1993, the young people in his pro- He also served as chairman the 44th volume of the Surgical gram and of his coworkers. of the Merit Review Board for Forum was dedicated to Jim, He learned early in life that Surgery of the U.S. Veterans and in 1996 the American Col- the main responsibility of an Administration, a director for lege of Surgeons selected him academic leader is to help and six years of the American Board for the Distinguished Service nurture and mentor those of Surgery, an associate editor Award. He received a simi- under him, and that the ac- of the Yearbook of Surgery, and lar award from the National complishments of the troops a member of the editorial board Medical Association and a ultimately reflect glory, not of the Journal of the American Lifetime Achievement Award only on themselves but also on College of Surgeons. from the Society of University the leader. He strongly believed Surgeons. that their success was his suc- Contributions to education cess. During many of our con- Arguably, Jim Thompson’s Qualities of character versations over the years, often most lasting contributions were and personality with obvious pleasure, he ex- in education. He trained 131 The most important and tolled the abilities and virtues research fellows from the U.S. lasting attributes of a man are of his people. In preparing this and 18 foreign countries in the the qualities of his character memorial tribute, I carefully fundamentals of scientific re- and personality. In regard to examined his curriculum vitae. search. Along with his faculty Jim Thompson, those quali- As a reflection of his nurturing colleagues, he trained more ties were his essence. The first —and it is only a sample—of than 200 residents in clinical quality was his incredible te- his 616 peer-reviewed publica- surgery. Twelve of his students nacity and determination. His tions, Courtney Townsend, MD, advanced to the position of background is a story of “we FACS, was a co‑author in 245; chairman of the department of shall overcome”: He overcame Mark Evers, MD, FACS, in 51; surgery and/or full professor a background of near pov- Dan Beauchamp, MD, FACS, in at major universities. During erty in a small Texas town; he 43; Gerald Fried, MD, FACS, the course of his career, he was overcame poverty that forced in 15; David Herndon, MD, invited 265 times to serve as a him to interrupt his medical FACS, in 14; Bill Nealon, MD, visiting professor at universi- education; he overcame lack of FACS, in 12; and Hugo Villar, ties in the U.S., Europe, the recognition in his residency at MD, FACS, in 9. Jim Thompson Far East, India, Africa, South Penn; and he overcame being was and will remain a model of America, and Central America. shunted to a backstream hospi- effective leadership. His influence on the education tal at the start of his academic The third Thompson attri- of surgeons was worldwide. career. With determination and bute, and one that few surgeons tenacity and no athletic experi- possess, is in the area of non- Honors ence, at the age of 60, he took medical culture. Jim Thompson Among his many honors, the up snow skiing and gave it up was truly a cultured man, with two that he prized most highly some years later only after he serious interests and knowl- were his elections to the Insti- sustained a hip fracture on the edge in literature, art, and tute of Medicine of the National slopes. Importantly, as a result music. Many of his colleagues Academy of Sciences and to the of determination, tenacity, and considered him to be the most American Philosophical Soci- ability, he changed UTMB and cultured person in the city of ety. In addition, he was elected built one of the leading surgical Galveston, a most unusual ac- to membership in 56 national scientific programs in the U.S., colade for a surgeon. One had professional and scientific orga- where nothing like it existed only to visit the large Thomp- nizations. Ten foreign surgical when he arrived in Galveston. son home on Bayou Shore Drive 44

VOLUME 93, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS to experience striking confirma- down)—that is, the quality of dents, residents, research fel- tion of these cultural interests. loyalty. Jim Thompson was lows, and coworkers—young The walls in every room were intensely loyal to his friends, and mature alike—as an inspi- lined by bookcases filled with a to his colleagues, to his depart- rational teacher and role model wide array of books, both non- ment, to his institution UTMB, of what a university professor fiction and fiction. Jim was the and to Texas. I sometimes should be. He will be remem- most avid reader whom I have asked myself, if I were in the bered by his colleagues and the known. The walls and ceilings trenches with the Viet Cong or surgical profession as a leader of every room, including the North Koreans coming at me who influenced the course of kitchen, were papered with with guns blazing, who would a great university. He will be original artwork from all over I want in the trenches with remembered by his many, many the world. And the collection me? The answer was, without friends as a warm, thoughtful, of classical and modern music doubt, Jim Thompson. generous, loyal, and engaging CDs and tapes was staggering. The final attribute that de- man who enriched the lives of You might ask, “What did these serves comment is his warmth all who had the good fortune of interests have to do with his job of personality. Words that char- coming to know him. And, of as a chair of the department of acterize his personality include course, he will be sorely missed surgery?” They enhanced his colorful, irreverent, sometimes by his six children, five grand- understanding of his patients outrageous, funny, bombastic, children, longtime companion and of the human condition. eloquent, occasionally inoffen- Bebe Jensen, and the entire Moreover, his cultural interests sively vulgar, charming, and Orloff family who knew him as made him a most interesting engaging. He was never dull. Uncle Jim. colleague and friend—far out Above all, he was fun to be of the ordinary. with in social situations and an Dr. Orloff is Distinguished Pro- The fourth attribute that unforgettable friend. I doubt fessor of Surgery, Emeritus, in the deserves comment is a quality that there will ever be another department of surgery at University that many find wanting when professor of surgery like him. of California–San Diego. they face difficult choices (as Jim Thompson will be re- they say, when the chips are membered forever by his stu-

• View surgical news • Interact with surgical communities • Update CME credits • Enter case log information • Track resident hours and more—all at: e-facs.org

45

NOVEMBER 2008 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS THE AMERICAN COLLEGE OF SURGEONS • DIVISION OF EDUCATION ACS Multimedia Atlas of Surgery

Volume I: Colorectal Surgery

Editors: Tonia M. Young-Fadok, MD, MS, FACS, FASCRS Horacio J. Asbun, MD, FACS

The Executive Committee on Video-Based Education and Ciné-Med have developed To order, the interactive Multimedia Atlas of Surgery. Each volume presents a comprehensive list of call 800/633-0004 surgical procedures, featuring: or visit • Narrated surgical video Formats: • Didactic presentations • DVD-ROM www.cine-med.com • Medical illustrations • Online • Expert commentary • Podcast • Foreword by Ajit K. Sachdeva, • Monograph MD, FACS, FRCSC, Director, Division of Education, American College of Surgeons

Pricing: DVD-ROM with monograph, online access, and podcast downloads: $270 1-year online subscription: $180 Individual chapters: $35 each (CD-ROM) $20 each (1-year online subscription)

Presented by

American College of Surgeons • Division of Education: “Improving the Quality of Surgical Care through Education”

Atlas of Surgery ad (Feb 08) - B1 1 3/11/2008 4:14:00 PM Germany Traveling Fellow selected for 2009

Richard A. Santucci, MD, April 28–May 1, 2009. He will FACS, professor of urology attend and participate in the in the College of Osteopathic ACS’ Germany Chapter meet- Medicine at Michigan State ing during that event. Dr. San- University, East Lansing, has tucci will also travel to several been selected as the 2009 surgical centers in Germany, ACS Traveling Fellow to Ger- with assistance from mentors many. provided by the German Surgi- Dr. Santucci has researched cal Society and the Germany and written extensively on Chapter. genitourinary trauma and The application deadline for reconstruction, as well as on the 2010 Traveling Fellowship more customary urological to Germany is April 1, 2009. topics. The requirements will be pub- As the Germany Traveling lished in a future edition of the Fellow, Dr. Santucci will par- Bulletin and have been posted ticipate in the annual meet- to the College’s Web site at ing of the German Surgical http://www.facs.org/member Dr. Santucci Society in Munich, Germany, services/acsgermany.html.

Dr. Eastman appointed to national injury prevention advisory board

The Board of Scientific Coun- center. The board also performs selors, National Center for second-level peer review of appli- Injury Prevention and Con- cations for grants-in-aid for re- trol, has appointed A. Brent search and research training ac- Eastman, MD, FACS, to serve tivities, cooperative agreements, on the 13-member board that and research contract proposals advises the Secretary of the related to the broad areas within U.S. Department ofHealth the national center. and Human Services and the A Fellow of the College since Director of the Centers for Dis- 1976, Dr. Eastman has served on ease Control and Prevention. the Board of Regents since 2001 The board will examine strate- and has been an active partici- gies and goals for programs and pant in its trauma programs and research within the national activities. He is currently the center, conduct peer review of chief medical officer at Scripps scientific programs, and moni- Health and N. Paul Whittier tor the overall strategic direc- Chair of Trauma, Scripps Memo- Dr. Eastman tion and focus of the national rial Hospital, La Jolla, CA. 47

NOVEMBER 2008 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS 2009 Coding Workshops

American College of Surgeons 2009 Coding Workshop Series for Surgeons and Their Staff

FT. LAUDERDALE, FL CHICAGO, IL February 26 JuLy 9 2009 Introduction to CPT, 2009 Introduction to CPT, ICD-9-CM, and evaluation ICD-9-CM, and evaluation For more information and Management Coding and Management Coding and to register, go to February 27 JuLy 10 http:// 2009 Surgical and 2009 Surgical and Office-based Coding and www.facs.org/ Office-based Coding and reimbursement (advanced) reimbursement (advanced) ahp/workshops/ ST. LOUIS, MO index.html LOS ANGELES, CA or contact May 14 auGuST 27 Debra Mariani, 2009 Introduction to CPT, 2009 Introduction to CPT, ICD-9-CM, and evaluation Practice affairs associate, ICD-9-CM, and evaluation and Management Coding tel. 202/672-1506, and Management Coding May 15 e-mail [email protected] auGuST 28 2009 Surgical and 2009 Surgical and Office-based Coding and Office-based Coding and reimbursement (advanced) reimbursement (advanced)

2009 Coding Workshop ad-Bulletin1 1 9/17/2008 4:24:45 PM Report of the 2008 American College of Surgeons Japan Traveling Fellow by Sam M. Wiseman, MD, FACS, FRCSC

The objectives of my visit to Japan were to attend the 108th Congress of the Japan Surgical Society (JSS) in Na- gasaki, stimulate scientific exchange, and develop new friendships and research col- laborations. I was readily able to accomplish these objectives during the Japan Traveling Fellowship, with my wife Natalie eagerly accompanying me, and I am already planning a future visit.

Tokyo I arrived in Tokyo before the JSS meeting to visit the Nippon Medical School where I was hosted by Prof. Kazuo Shimizu, MD, PhD, chairman of the department of sur- Dr. Wiseman with his host in Tokyo, Professor Shimizu. gery (see photo, this page). The first day of my visit was spent in the operating room (OR) with Professor Shimizu, where I had the opportunity to Over lunch with junior staff, inpatient wards, radiology, and watch him carry out a thyroid- residents, and students, we the laboratory. Kiyomi Yamada ectomy and neck dissection for had in-depth discussions on Hames, MD, PhD, a clinical cancer. I was very impressed many interesting topics. I es- fellow in endocrine surgery with the intraoperative teach- pecially enjoyed learning about who had recently returned ing and mentorship he gave the use of adjuvant therapy from completing her research to junior surgical staff, sur- for thyroid cancer in Japan. training in Boston, MA, was gical residents, and medical We also had the opportunity an excellent tour guide and students. It was in the OR to discuss the video-assisted taught me much about the with Professor Shimizu that neck surgery approach to thy- medical system in Japan. It I had my first opportunity to roid and parathyroid surgery, was thrilling to visit the beau- observe a lateral neck dissec- a technique that Professor tiful Shinto shrine located tion in Japan. We also spoke Shimizu has pioneered. just across the street from the at length about the extent of I had the opportunity to tour medical school. lymphadenectomy for thyroid the Nippon Medical School I also had the opportunity cancer. and visit the outpatient clinic, to meet and speak with many 49

NOVEMBER 2008 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS endocrine surgeons and train- ees at the school, including associate professors Haruki Akasu, MD, PhD, and Takehito Igarashi, MD, PhD; assistant professor Ritsuko Okamura, MD, PhD; and clinical fellow Tomoo Jikuzono, MD. Ev- eryone was very friendly and welcoming and I was able to answer many questions for them regarding thyroid and parathyroid surgical surgery in Canada. I also had the plea- sure of meeting and speaking with Koji Yamashita, MD, PhD, about his experience using a transaxillary retromammary, video-assisted breast surgery (VABS) approach for breast conservation surgery. The weekend was spent Dr. Wiseman with his host in Kobe, Professor Miyauchi. sightseeing with Natalie in Tokyo, an incredibly large and diverse city with a very efficient and user-friendly mass transit system. Sight- cal management of adrenal Kobe seeing highlights from the tumors. The next stop was Kobe, weekend included attending The following morning, I was where I visited the Kuma Hos- sumo wrestling matches in the warmly received at the Nip- pital and was hosted by Prof. Kokugikan arena, visiting the pon Medical School surgical Akira Miyauchi, MD, PhD, Asakusa Shrine and Tsukiji rounds and report. At rounds, director of the thyroid disease- Fish Market, and exploring the I heard a very interesting pre- focused medical center (see Shinjuku, Ginza, and Shibuya sentation on VABS for in situ photo, this page). I attended areas. The Akihabara “Elec- breast cancer and delivered a the hospital’s morning confer- tric Town” was overwhelm- presentation on my research of ence where I very much enjoyed ing, with more electronics on molecular diagnostic markers presentations on several topics display and for sale than I for thyroid cancer. There were that included musculoskeletal could have ever imagined was many interesting comments complaints experienced in pa- possible. and questions and the discus- tients with Graves disease and The highlight of the week- sion that followed was stimu- controversies related to poorly end was an authentic Japa- lating. Before my departure, I differentiated thyroid cancer. nese meal hosted by Professor spoke with Professor Shimizu Professor Miyauchi gave me Shimizu in a beautiful venue and Dr. Hames about several a tour of the hospital, an im- located in a lush park in To- future collaborative research pressive facility that provides kyo. Many interesting discus- projects. After rounds, we were multidisciplinary care for indi- sions over dinner included the off to Kobe on the shinkansen viduals diagnosed with thyroid current surgical approach to (bullet train) that we found to disease. I spent the morning parathyroid disease in Japan be a fast and pleasant way to with Professor Miyauchi in his and minimally invasive surgi- travel the country. outpatient clinic, reviewing a 50

VOLUME 93, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS large number of patients with lecular markers for improving society as the representative thyroid and parathyroid dis- thyroid cancer diagnosis at this of the American College of ease. The topics of discussion symposium. The discussion was Surgeons. I was very proud ranged from surgical manage- terrific and I answered several and honored to represent the ment of medullary carcinoma questions on my research that ACS at this event. I also met to the unique experience at the has focused on anaplastic thy- Thomas R. Russell, MD, FACS, Kuma Hospital of long-term roid cancer. It was a pleasure ACS Executive Director, who surveillance for individuals to meet and chat with Yasuhiro was giving a lecture at the diagnosed with papillary mi- Ito, MD, an endocrine surgeon JSS congress, and Susumu crocarcinoma. at Kuma who, like myself, has Eguchi, MD, PhD, FACS, who The afternoon was spent in a research interest in thyroid had assisted me with planning the OR observing several of the cancer molecular biology. my visit. After dinner, I was skilled surgeons at Kuma per- Before my departure, I had honored to be congratulated by forming thyroid and parathy- the opportunity to speak fur- many members of the society roid operations. This experi- ther with Professor Miyauchi for being selected as the Trav- ence was interesting and very on several other topics, includ- eling Fellow. different from my experience ing a review of his technique The JSS congress was held in North America, as there of lateral mobilization of the at the Nagasaki Brick Hall, a were two operations going on recurrent laryngeal nerve to large conference center, and simultaneously in each surgi- facilitate tracheal resection in several meeting sessions were cal theater, and doors between patients with thyroid cancer held in surrounding hotels. ORs allowed me to see several invading the trachea near the My personal highlights of the other thyroid operations occur- ligament of Berry. conference included the endo- ring simultaneously. I observed Kobe was a beautiful city and crine surgical session chaired several thyroidectomies for before Natalie and I left, we by Shigeto Maeda, MD, PhD. I thyroid cancer, including sev- took a ride on the Shin-Kobe especially enjoyed a presenta- eral lymph node dissections, cable car to the top of a moun- tion given by Makoto Kam- several thyroidectomies for tain that had a beautiful view mori, MD, PhD, of Tokyo, that goiter, and resection of a para- of both the city and the sea. evaluated the diagnostic utility thyroid carcinoma. All the en- of telomere length in follicular docrine surgeons were friendly Nagasaki thyroid lesions. and we had many discussions I then took the shinkansen As part of the congress, I focused on technical aspects of and train to Nagasaki for the also gave a lecture during this their thyroid operations. 108th annual congress of the session on my research evalu- In the evening, there was a JSS. The meeting began with ating the molecular pheno- research mini-symposium at the council dinner, where type of differentiated thyroid which several of the Kuma staff Natalie and I were warmly cancer. My lecture generated gave presentations of their welcomed by the president, an interesting discussion and work that would be presented Prof. Takashi Kanematsu, several questions. Overall, it at upcoming meetings. The MD, and Ms. Kanematsu. At was encouraging for me to see presentation topics included this dinner, we were seated that, like in North America, poorly differentiated thyroid with several members of the surgeon-scientists in Japan cancer and intrathyroid epi- society, including Prof. Koichi are carrying out excellent thelial thymoma/carcinoma Tabayashi, MD, Prof. Hiroshi research. showing thymus-like differen- Takami, Prof. Akira Kawagu- Another highlight of the tiation lesions (an uncommon chi, and visiting pioneering JSS for me was the minimally thyroid tumor originally de- cardiac surgeon/conference invasive thyroid surgery video scribed by Professor Miyauchi speaker Randas J.V. Batista, session. Pioneers in a wide at Kuma Hospital). MD, of Brazil. I was intro- variety of minimally invasive I gave a presentation on mo- duced to the members of the approaches to thyroid surgery 51

NOVEMBER 2008 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS very moved by the Nagasaki atomic bomb museum and me- morial.

Beppu My next destination was the Noguchi Thyroid Clinic and Hospital in Beppu. Beppu is a quaint town known in Ja- pan for its many natural hot springs. While visiting the No- guchi Hospital, I was hosted by Prof. Shiro Noguchi, MD, PhD, director of this medical center that, like Kuma, is focused on thyroid disease. I was greeted by Hitoshi Noguchi, MD, and Shiro Noguchi upon my arrival (see photos, page 53). Initially I toured around this facility and was shown the inpatient wards, outpatient department, radiol- ogy, and laboratory. Afterward, Hitoshi Noguchi and I spoke at length about Dr. Wiseman receiving a certificate commemorating his ACS Traveling multiple issues related to the Fellowship to Japan from Professor Takami on behalf of the Japan Surgical management of thyroid can- Society. cer. I learned that, like me, he had an interest in studying new treatments for anaplastic thyroid cancer and he shared with me the results of some of presented videos and discussed ship (see photo, this page). his recent study. I also gave a their operative techniques. I Natalie and I very much presentation of my research was impressed with the inno- enjoyed the informal dinner evaluating novel treatments for vation, resourcefulness, and hosted by Shigeto Maeda, MD, anaplastic thyroid cancer. This technical expertise evident in PhD, and his colleagues from generated many questions, these videos. Other lectures Nagasaki University, that al- stimulated further discussion, and poster sessions I attended lowed me to chat with many of and we decided that we would at the JSS congress further im- the endocrine surgeons I had collaborate in the future on pressed me with the high level met on my trip, including Prof. anaplastic thyroid cancer- of scholarship maintained by Shimizu from Tokyo, Yasuhiro related research projects. Japanese surgeons. I especially Ito from Kobe, Makoto Kam- I spent the afternoon observ- enjoyed meeting several of the mori from Tokyo, and others. ing several thyroid operations international JSS travel grant I enjoyed speaking with Dr. carried out by the skilled endo- recipients, and it was a great Maeda about endocrine sur- crine surgeons at the hospital. I honor being presented with gery in Nagasaki. observed several operations for a certificate from the JSS by While visiting Nagasaki, we both benign and malignant thy- Prof. Hiroshi Takami to com- had the opportunity to visit roid disease, including a locally memorate my travelling fellow- several tourist sites and were advanced thyroid cancer, and it 52

VOLUME 93, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Dr. Wiseman with his hosts in Beppu, Prof. Shiro Noguchi (left) and Dr. Hitoshi Noguchi.

was very exciting for me to see departure, we had the oppor- for the great honor of serv- that for some thyroid surger- tunity to visit their famous ing as its representative and ies, an electrothermal vessel natural hot springs. giving me the opportunity to sealing system was used. visit several excellent Japanese At the end of the day, I had Reflections surgical centers, to exchange an opportunity to speak with On the way to the airport in ideas, to learn, and to develop Shiro Noguchi on several topics Osaka, we visited the atomic new academic collaborations including the management of bomb memorial in Hiroshima and friendships. papillary microcarcinoma, and and spent a day touring Kyoto, how he had recently reported one of the most beautiful cities Dr. Wiseman is a surgical oncolo- that tumors between 6 mm I have ever seen. The impres- gist, head and neck surgeon, gen- and 10 mm behave in a fashion sive beauty of the many shrines eral surgeon, and scientist in the similar to larger tumors. We and gardens in Kyoto really department of surgery, St. Paul’s also discussed the extent of must be seen to be believed. My Hospital, University of British Columbia, Vancouver. lymphadenectomy for thyroid visit to Japan was a very busy cancer. but a wonderful experience for The multidisciplinary confer- Natalie and me. I found all my ence that followed reviewed Japanese colleagues to be fan- many interesting cases and I tastic hosts and their technical was impressed with the high expertise, academic focus, and level of scholarship displayed science to be at a very high lev- at this meeting. Beppu was a el. I wholeheartedly thank the beautiful city and before our American College of Surgeons 53

NOVEMBER 2008 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS Is your cancer program ready?

Programs accredited by the Commission on Even more, CoC-accreditation earns recognition Cancer (CoC) of the American College of Surgeons from national health care organizations for meeting make a commitment to their patients to invest performance measures for high-quality cancer care. their resources in the best available methods for The American Cancer Society also acknowledges the early detection and treatment of cancer. And and supports the importance of CoC accreditation the Commission is there–every step of the way–to through its National Cancer Information help each accredited program meet the challenge. Center and other patient-focused resources. The Commission on Cancer provides a model for Patients rely on your facility to provide a managing your facility’s cancer program by: comprehensive approach to their cancer care, and the Commission on Cancer can help  Setting standards to promote high- your program provide access to the highest quality, multidisciplinary patient care level of cancer care for your patients.  Facilitating ongoing assessment of your program’s activities  Providing real-time access to National Cancer Data Base data to evaluate and improve your delivery of care

Get ready. Learn about the Commission on Cancer Approvals Program today. Visit the Commission’s Web site at: www.facs.org/cancerprograms/mh08 Or send an E-mail query to: [email protected]

Administrator Ad 2008 full page 1 1 4/30/2008 1:22:17 PM A look at The Joint Commission International focus on accreditation

The term “medical tourism” is benchmarks for accreditation. at JCI-accredited organizations gaining recognition in the U.S. as The standards and survey pro- are local residents. JCI helps the media increasingly are shin- cess have been adapted for the countries educate organizations ing a spotlight on the growing international community and and staff on how to achieve im- trend of Americans, particularly are designed to be culturally ap- proved quality and safety. JCI the uninsured, traveling over- plicable and in compliance with also helps ministries of health to seas for low-cost medical care. laws and regulations in countries develop their own standards and As a result of this trend, The outside the U.S. The standards establish their own accrediting Joint Commission’s interna- were developed by international bodies. tional accrediting arm, Joint experts and set uniform, achiev- JCI is accredited by the Inter- Commission International (JCI), able expectations for structures, national Society for Quality in is also garnering a fair amount processes, and outcomes for Health Care and extends The of attention. JCI is recognized health care organizations. The Joint Commission’s mission around the world for its rigor- requirements for accreditation worldwide by assisting inter- ous and comprehensive set of also include international pa- national health care organiza- international standards. JCI, tient safety goals, which high- tions, public health agencies, a division of Joint Commis- light problematic areas in health health ministries, and others to sion Resources Inc. (JCR)—a care and describe evidence and improve the quality and safety private, not-for-profit affiliate expert-based consensus solu- of patient care in more than 80 of The Joint Commission—was tions to these problems. The countries. JCI is headquartered established in 1997 and began survey process is designed to in Oakbrook, IL, and has interna- accrediting organizations out- accommodate specific legal, tional offices located in Ferney- side the U.S. in 1999. JCI offers religious, and cultural factors Voltaire, France; Milan, Italy; accreditation for hospitals, am- within a country. Dubai, UAE; and Singapore. bulatory care facilities, clinical Although some of the orga- For more information on JCI, laboratories, care continuum nizations accredited by JCI visit www.jointcommission services, primary care facilities, serve medical tourists, the vast international.org or call 630/268- and medical transport organi- majority of the patients served 7400. zations, as well as certification in disease- or condition-specific care. Today JCI accredits and Trauma meetings calendar certifies more than 200 organiza- tions in 33 countries. The following continuing medi- & Acute Care Surgery 2009– For Americans traveling cal education courses in trauma Point/Counterpoint XXVIII, abroad for medical treatment, are cosponsored by the American June 8–10, 2009, Atlantic City, whether an organization is ac- College of Surgeons Committee NJ. credited by JCI is one way to on Trauma and Regional Com- Complete course informa- mittees: tion can be viewed online (as it assess the quality and safety • Advances in Trauma, De- becomes available) through the of an organization where they cember 12–13, Kansas City, MO. American College of Surgeons’ are considering undergoing a • Trauma, Critical Care, Web site at http://www.facs. procedure. & Acute Care Surgery–2009, org/trauma/cme/traumtgs.html, JCI’s standards, training, and April 6–8, 2009, Las Vegas, NV. or contact the Trauma Office at processes used during the survey • Trauma, Critical Care, 312/202-5342. meet the highest international 55

NOVEMBER 2008 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS ACOSOG news “Such stuff as dreams are made on”: Laparoscopic rectal cancer trial by David M. Ota, MD, FACS; and Heidi Nelson, MD, FACS

The famous Shakespearean Only through a prospective, life, sexual function, and bowel line (The Tempest) about illu- randomized trial design can and stoma function at sched- sion that is cited in the title of we answer this question and uled time points throughout this column seems appropriate others. the trial. to new laparoscopic procedures. The American College of Currently, there is no level I These procedures are receiv- Surgeons Oncology Group evidence that laparoscopic re- ing gradual acceptance in our (ACOSOG) has recently acti- section of rectal cancer produces surgical practice. This incre- vated protocol Z6051, A Phase the same histopathologic out- mental acceptance of minimally III Prospective Randomized come compared with open resec- invasive surgery (MIS) is more Trial Comparing Laparoscop- tion. Potential concerns with pronounced with cancer because ic-Assisted Resection versus laparoscopic resection include there are concerns related to ef- Open Resection for Rectal Can- less visualization of the pelvis ficacy and safety when compared cer. The primary objective is and exposure of the mesorectum with standard surgical resection. to test the hypothesis that and adjacent structures, such Local control of primary ma- laparoscopic-assisted resection as hypogastric nerves. A recent lignant disease is a priority for for rectal cancer is not inferior prospective, randomized trial of surgeons who treat resectable to open rectal resection based laparoscopic surgery for either disease. This is of greatest con- on pathologic analysis of the colon or rectal cancer suggested cern when MIS is considered for resected specimen. an increased risk of positive cir- primary resectable rectal cancer. This analysis will include a cumferential radial margin with As with laparoscopic colectomy, circumferential tumor margin the laparoscopic approach,* laparoscopic approaches to low >1 mm, distal resection margin which did not result in a higher anterior resection, coloanal re- >2 cm (or >1 cm with clear fro- local recurrence, but the trial section, and abdominoperineal zen section in the low rectum) was not powered to address this resection are technically feasible and completeness of transmeso- issue in rectal cancer. with improved instrumentation rectal excision. These are cru- The patient eligibility criteria and greater surgeon skill. cial benchmarks in evaluating for Z6051 include the following: Although many of us can ap- the quality of surgical resection • Histologic diagnosis of preciate the potential patient of primary rectal cancer. adenocarcinoma of the rectum recovery benefits of perform- Secondary objectives of (<12 cm from the anal verge) ing these procedures, do they the trial include assessment • T3N0M0, TanyN1M0 dis- achieve the same local cancer of patient-related benefit of ease as determined by pretreat- control rate of open resection? laparoscopic-assisted resection ment computed tomography for rectal cancer versus open scans and pelvic magnetic reso- *Guillou PJ, Quirke P, Thorpe H, et al. rectal resection (blood loss, nance imaging or transrectal Short-term endpoints of conventional length of stay, pain medicine ultrasound; patients with T4 versus laparoscopic-assisted surgery utilization); assessment of dis- disease extending to circum- in patients with colorectal cancer (MRC CLASICC trial): Multicenter, ease-free survival and local ferential margin of rectum or randomized controlled trial. Lancet. pelvic recurrence at two years; invading adjacent organs are 2005; 365:1718-1726. and assessment of quality of not eligible 56

VOLUME 93, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS • Completion of preopera- tating, as confirmed by pretreat- study chair, can be contacted at tive 5FU-based chemothera- ment pregnancy test for patients [email protected]. py and/or radiation therapy; of childbearing potential Z6051 is very much a suc- capecitabine may be substituted • No concurrent or previ- cessor trial to the laparoscopic for 5FU ous invasive pelvic malignancy colectomy trial† but with a dif- • Age >18 years (cervical, uterine, and rectal) ferent primary endpoint. Pro- • Eastern Cooperative On- within five years before regis- spective phase III randomized cology Group (Zubrod) perfor- tration trials for new procedures in mance status <2 • No history of psychiatric cancer treatment are needed to • Body mass index <34 or addictive disorders or other demonstrate that such techni- • No evidence of conditions conditions that, in the opinion cal advances are not inferior to that would preclude use of a of the investigator, would pre- standard procedures and that laparoscopic approach (for ex- clude the patient from meeting there is measurable improve- ample, multiple previous major the study requirements ment in quality of life. laparotomies, severe adhesions) As with all ACOSOG proce- The National Cancer Institute • No systemic disease (car- dure trials, there are surgeon has designated Z6051 as a high- diovascular, renal, hepatic, and credentialing criteria to par- priority trial. ACOSOG needs so forth) that would preclude ticipate as an investigator in the your involvement in order for surgery; no other severe, in- trial. Credentialing in laparo- surgeons to establish the valid- capacitating disease—that is, scopic colon and rectal surgery ity and safety of the procedure. American Society of Anesthe- are required. Credentialing As a surgeon-oriented coopera- siologist classification of IV (a for laparoscopic colectomy and tive group, ACOSOG will con- patient with severe systemic laparoscopic rectal surgery both tinue to develop and conduct disease that is a constant threat require 20 laparoscopic or hand- procedure-oriented national to life) or V (a moribund patient assisted operations. Laparoscop- trials. To date, ACOSOG has who is not expected to survive ic cases for benign tumors or non- achieved considerable success without the operation) neoplastic diseases can be in- with such trials and the commit- • Nonpregnant and nonlac- cluded in credentialing cases. ment of the ACOSOG members Further details are found in is very much appreciated. †Clinical Outcomes of Surgical the protocol, which can be ac- Therapy Study Group. A comparison Dr. Ota, of Durham, NC, and Dr. of laparoscopically assisted and open cessed on the ACOSOG Web site (www.acosog.org). James Nelson, of Rochester, MN, are colectomy for colon cancer. N Engl J ACOSOG co-chairs. Med. 2004;350:2050-2059. Fleshman, MD, FACS, protocol

2009 Oweida Scholarship availability announced

The Board of Governors of Pennsylvania. The purpose of say describing why the applicant the American College of Sur- the Oweida Scholarship is to en- characterizes his or her practice geons is pleased to announce able young surgeons practicing as rural and why he or she would the availability of the 2009 Ni- in rural communities to attend like to receive the scholarship. zar N. Oweida Scholarship. The the Clinical Congress and benefit The deadline for receipt of appli- Oweida Scholarship, an annual from the educational experiences cation materials is December 15, award administered by the Ex- it provides. The $5,000 award 2008. For the complete require- ecutive Committee of the Board subsidizes attendance at the an- ments for this scholarship, visit of Governors, was established in nual Clinical Congress, including http://www.facs.org/member 1998 in memory of Dr. Oweida, postgraduate course fees. services/oweida.html or contact a general surgeon who prac- Applications consist of a cur- the Scholarships Administrator ticed in a small town in western riculum vitae plus a one-page es- at [email protected]. 57

NOVEMBER 2008 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS a member benefit from resIDent memBers SDIF| the american College of surgeons Time is your GreaTesT asseT

Investment $ after 40 Let the power 1,000,000 years: • $1,082,949 of compounding 800,000 You have worked Investment hardwork and spent for time and you. money to be where you 600,000 after 30 • years: are. Now you can put both time and money to work 400,000 • $405,821 • for you by investing $100 per month in an account 200,000 • with SDIF. Starting early on, a regular program of • • investing can make a tremendous difference over 0 • • • • ••• time. The charted hypothetical example illustrates years 5 10 15 20 25 30 35 40  the difference between two investors who invest Assuming $100 invested per month, 10% annual increase in amount identical amounts, starting with $100 per month, invested, and 6% average annual return. and increase their contributions by 10% each year. This hypothetical does not represent the returns of any particular The chart assumes an average annual return of investment. An investment in the Fund may have very different results. 6%, compounded monthly. The only difference is Past performance is no guarantee of future returns. that one investor starts today, and the other starts 10 years from now. Forty years later, the investor who started early has a portfolio of more than $1 million. The investor who started later has only $400,000. take advantage of your greatest asset. invest now.

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An investor should consider the investment objectives, risks, and charges and expenses of SDIF carefully before investing. SDIF’s prospectus contains this and other information about SDIF and should be read before investing. SDIF’s prospectus may be obtained by downloading it from SDIF’s Web site at www.surgeonsfund.com or by calling 800/208-6070. A program of regular investing does not ensure a profit or protect against depreciation in a declining market. Because a consistent investing program involves continuous investment in securities regardless of fluctuating prices, you should consider your financial ability to continue to purchase through periods of various price levels. SDIF is distributed by Ultimus Fund Distributors, LLC, 225 Pictoria Dr., Suite 450, Cincinnati, OH 45246. The phone number is 513/587-3400.

Resident Compound Ad Final Art.i1 1 9/24/2008 2:49:08 PM NTDB® data points ATVs: “All-terrain victims” by Richard J. Fantus, MD, FACS

It is now the middle of fall, and all-terrain vehicle (ATV) Number of incidents by age group use is in full gear. It is not uncommon in the Midwest to hear of an ATV-related fatal- ity on a regular basis this time of year. According to the U.S. Consumer Product Safety Com- mission (CPSC), the number of estimated injuries treated in the emergency room has almost tripled over the most recent 10-year period for which data are available, from 53,500 in 1996 to almost 150,000 in 2006. Along with this increased number of injuries has been an estimated threefold increase in deaths from 267 in 1996 to 870 in 2006. In 2006, deaths in children younger than 16 years of age accounted for ap- proximately 20 percent of the fatalities (http://www.atvsafety. gov/stats.html). The CPSC has stated that eases, Ninth Revision, Clinical The Specialty Vehicle Insti- ATVs are one of the deadliest Modification cause of injury tute of America points out that a products under their jurisdic- code E 821, accident involving vast majority of the ATV-related tion. The agency has worked for off-road motor vehicles (which accidents and fatalities involve 20 years trying to make ATVs include ATVs), and further sort- rider error. There is a chasm safer. Aside from a decree in the ed to identify injury to driver, between the industry and the 1980s to ban the sale of three- 821.0, or to passenger, 821.1. protection agency. There are wheel models, there has been This search resulted in 58,235 some valuable precautions one very little progress in recent records, composed of 35,665 can take in order to mitigate years. drivers, 6,859 passengers, and potential injury, such as keep- In order to examine the po- 15,711 other/unspecified. These ing the vehicle off paved roads, tential occurrence of injuries records were then divided to as- avoiding tandem rides, wearing sustained while on an ATV, the sess the ages of victims in these a helmet, not driving under the National Trauma Data Bank® incidents. There was an increase influence of alcohol, and not (NTDB) Dataset 7.1 records in incidents among younger ATV allowing children to operate were searched using the Inter- users. These data are depicted in adult-sized ATVs. To take it one national Classification of Dis- the graph on this page. step further, the American As- 59

NOVEMBER 2008 BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS sociation of Pediatrics suggests Version 7.0 is available on the has been provided by Sandra M. that no children younger than ACS Web site as a PDF and a Goble, MS. 16 years drive ATVs regardless PowerPoint presentation at of the model and whether an http://www.ntdb.org. Dr. Fantus is director, trauma automobile driver’s license is If you are interested in sub- services, and chief, section of surgical critical care, Advocate required to operate one. mitting your trauma center’s Illinois Masonic Medical Center, We all make choices in life, data, contact Melanie L. Neal, and clinical professor of surgery, and if one of yours puts you Manager, NTDB, at mneal@ University of Illinois College of on the back of an ATV, be sure facs.org. Medicine, Chicago, IL. He is Chair to heed the above so your ATV of the ad hoc Trauma Registry Ad- will not stand for “all-terrain Acknowledgment visory Committee of the Committee victim.” on Trauma. The full NTDB Annual Report Statistical support for this article

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VOLUME 93, NUMBER 11, BULLETIN OF THE AMERICAN COLLEGE OF SURGEONS