Preparation and Teamwork in Hurricane Season Contents

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FEBRUARY 2018 | VOLUME 103 NUMBER 2 | AMERICAN COLLEGE OF SURGEONS Bulletin

Preparation and teamwork in hurricane season Contents

FEATURES COVER STORIES: Preparation and teamwork in hurricane season Preparation, teamwork pay off during 2017 Atlantic hurricane season 10 Tony Peregrin

From the rescuers to the rescued: A tale of two hurricanes 18 Bolívar Arboleda-Osorio, MD, FACS

Olga M. Jonasson, MD, Lecture: The quiet pioneer who started a revolution: Elizabeth Garrett Anderson 22 Kathryn D. Anderson, MD, FACS

Precision surgical oncology? The treasure is in the tissue 30 Carolyn C. Compton, MD, PhD, FCAP, and Bruce J. Averbook, MD, FACS | 1 The history of the scalpel: From flint to zirconium-coated steel 34 Jason B. Brill, MD; Evan K. Harrison, MD; Michael J. Sise, MD, FACS; and Romeo C. Ignacio, Jr., MD, FACS

ACS manages 2017 legislative gains despite Hill focus on ACA repeal, tax reform 39 Kristin McDonald

FEB 2018 BULLETIN American College of Surgeons Contents continued

STATEMENT Your ACS benefits: Underused Coming next month in JACS resources every ACS member and online now 79 Statement on Cannabis Regulation should know about 61 Disciplinary actions taken and Risk of Injury 43 Connie Bura in 2017 80 Statement on Post-Traumatic Making quality stick: Optimal Stress Disorder in Adults 45 A look at The Joint Commission: Joint Commission publishes 2018 Resources for Surgical Quality Statement on Post-Traumatic National Patient Safety Goals 64 and Safety: Individual disciplines Stress Disorder in Pediatric working together in an increasingly Trauma Patients 47 Carlos A. Pellegrini, MD, FACS, FRCSI(Hon), FRCS(Hon), FRCSEd(Hon) regulated environment 81 Chapter news 83 COLUMNS NTDB data points: 2017 Pediatric Luke Moreau and Brian Frankel Looking forward 8 Annual Report: ICD-10 66 ACS in the news 92 David B. Hoyt, MD, FACS Richard J. Fantus, MD, FACS Letters to the Editor 68 Call for nominations for the What surgeons should know ACS Board of Regents and about...Regulatory burden ACS Officers-Elect 94 reduction 49 NEWS Stand out in 2018—update TQIP annual meeting shares Lauren Foe, MPH your ACS member profile 95 best practices, advances in 2 | From residency to retirement: trauma care 70 Nominations for 2018 Race and residency training in the volunteerism and humanitarian Tony Peregrin post-Charlottesville era 55 awards due February 28 96 Allison N. Martin, MD, MPH Leigh A. Neumayer, MD, MS, FACS, elected Chair of ACS Board ACS Clinical Research Program: SCHOLARSHIPS of Regents 76 Surgical management of ADH, ALH, Apply for International and LCIS 59 Register now to participate in Scholarships for Surgical 2018 Leadership & Advocacy Diana Dickson-Witmer, MD, FACS; Education by March 1 98 Summit 78 Amy C. Degnim, MD, FACS; Isabelle Bedrosian, MD, FACS; and Judy C. Brian Frankel, Michael Carmody, MEETINGS CALENDAR and Katie Oehmen Boughey, MD, FACS Calendar of events 100

V103 No 2 BULLETIN American College of Surgeons The American College of Surgeons is dedicated to improving the care of the surgical patient A Mirror Reflecting Surgery, and to safeguarding standards of care in an Surgeons, and their College: optimal and ethical practice environment. The Bulletin of the American

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Bulletin of the American College of Surgeons (ISSN 0002-8045) is published monthly by the American College of Surgeons, 633 N. Saint Clair St., Chicago, IL 60611. It is distributed without charge to Fellows, Associate Fellows, Resident and Medical Student Members, Affiliate Members, and to medical libraries and allied health personnel. Periodicals postage paid at Chicago, IL, and additional mailing offices. POSTMASTER: Send address changes to Bulletin of the American College of Surgeons, 3251 Riverport Lane, Maryland Heights, MO 63043. Canadian Publications Mail Agreement No. 40035010. Canada returns to: Station A, PO Box 54, Windsor, ON N9A 6J5. The American College of Surgeons’ headquarters is located at 633 N. Saint Clair St., Chicago, IL 60611-3211; tel. 312-202‑5000; toll-free: 800-621-4111; e-mail: [email protected]; website: facs.org. The Washington, DC, Office is located at 20 F Street N.W. Copies of this recently published book Suite 1000, Washington, DC. 20001-6701; tel. 202‑337-2701. are available for purchase from amazon.com. Unless specifically stated otherwise, the opinions expressed and statements made in this publication reflect the authors’ Price: $15.95 personal observations and do not imply endorsement by nor official policy of the American College of Surgeons. Published by the American College of Surgeons. ©2018 by the American College of Surgeons, all rights reserved. Contents may not be reproduced, stored in a retrieval system, or transmitted in any form by any means without prior written permission of the publisher. Library of Congress number 45-49454. Printed in the USA. Publications Agreement No. 1564382.

2017_BulletinAd_NahrwoldBook_Vertical_4.5x7.5in_v03.indd 1 2/14/2017 11:24:34 AM Officers and Staff of the American College of Surgeons

James K. Elsey, MD, FACS AMERICAN COLLEGE OF Officers Atlanta, GA Advisory Council SURGEONS FOUNDATION Henri R. Ford, MD, FACS Shane Hollett Barbara L. Bass, MD, FACS Los Angeles, CA to the Board Executive Director Houston, TX of Regents ALLIANCE/AMERICAN PRESIDENT Gerald M. Fried, MD, FACS, FRCSC COLLEGE OF SURGEONS Courtney M. Townsend, Jr., Montreal, QC (Past-Presidents) CLINICAL RESEARCH PROGRAM MD, FACS James W. Gigantelli, MD, FACS Kathryn D. Anderson, MD, FACS Kelly K. Hunt, MD, FACS Galveston, TX Omaha, NE Eastvale, CA Chair IMMEDIATE PAST-PRESIDENT B. J. Hancock, MD, FACS, FRCSC W. Gerald Austen, MD, FACS CONVENTION AND MEETINGS Charles D. Mabry, MD, FACS Winnipeg, MB Boston, MA Robert Hope Pine Bluff, AR Enrique Hernandez, MD, FACS Director FIRST VICE-PRESIDENT L. D. Britt, MD, MPH, Philadelphia, PA FACS, FCCM DIVISION OF EDUCATION Basil A. Pruitt, Jr., MD, Lenworth M. Jacobs, Jr., MD, FACS Norfolk, VA Ajit K. Sachdeva, MD, FACS, FCCM, MCCM Hartford, CT FACS, FRCSC San Antonio, TX John L. Cameron, MD, FACS Director SECOND VICE-PRESIDENT L. Scott Levin, MD, FACS Baltimore, MD Edward E. Cornwell III, Philadelphia, PA Edward M. Copeland III, MD, FACS EXECUTIVE SERVICES Fabrizio Michelassi, MD, FACS Gainesville, FL Maxine Rogers MD, FACS, FCCM Director, Leadership Operations Washington, DC New York, NY A. Brent Eastman, MD, FACS SECRETARY Linda G. Phillips, MD, FACS Rancho Santa Fe, CA FINANCE AND FACILITIES William G. Cioffi, Jr., MD, FACS Galveston, TX Gay L. Vincent, CPA Gerald B. Healy, MD, FACS Director Providence, RI Wellesley, MA TREASURER Anton N. Sidawy, MD, FACS Washington, DC HUMAN RESOURCES David B. Hoyt, MD, FACS R. Scott Jones, MD, FACS AND OPERATIONS Chicago, IL Beth H. Sutton, MD, FACS Charlottesville, VA Michelle McGovern Wichita Falls, TX 4 | EXECUTIVE DIRECTOR Edward R. Laws, MD, FACS Director Gay L. Vincent, CPA Gary L. Timmerman, MD, FACS Boston, MA INFORMATION TECHNOLOGY Chicago, IL Sioux Falls, SD LaSalle D. Leffall, Jr., MD, FACS Brian Harper CHIEF FINANCIAL OFFICER Steven D. Wexner, MD, FACS Washington, DC Director Weston, FL LaMar S. McGinnis, Jr., MD, FACS DIVISION OF INTEGRATED Douglas E. Wood, MD, Atlanta, GA COMMUNICATIONS Officers-Elect FACS, FRCSEd Lynn Kahn David G. Murray, MD, FACS Director (take office October 2018) Seattle, WA Syracuse, NY Michael J. Zinner, MD, FACS Patricia J. Numann, MD, FACS JOURNAL OF THE AMERICAN Ronald V. Maier, MD, FACS Coral Gables, FL COLLEGE OF SURGEONS Seattle, WA Syracuse, NY Timothy J. Eberlein, MD, FACS PRESIDENT-ELECT Carlos A. Pellegrini, MD, FACS Editor-in-Chief Seattle, WA Mark C. Weissler, MD, FACS Board of DIVISION OF MEMBER SERVICES Chapel Hill, NC J. David Richardson, MD, FACS Patricia L. Turner, MD, FACS FIRST VICE-PRESIDENT-ELECT Governors/ Louisville, KY Director Philip R. Caropreso, MD, FACS Executive Richard R. Sabo, MD, FACS M. Margaret Knudson, MD, FACS Iowa City, IA Bozeman, MT Medical Director, Military Health SECOND VICE-PRESIDENT-ELECT Committee Seymour I. Schwartz, MD, FACS Systems Strategic Partnership Diana L. Farmer, MD, FACS, FRCS Rochester, NY Sacramento, CA Girma Tefera, MD, FACS Board of Regents CHAIR Frank C. Spencer, MD, FACS Director, Operation Giving Back Steven C. Stain, MD, FACS New York, NY PERFORMANCE IMPROVEMENT Leigh A. Neumayer, MD, FACS Albany, NY Andrew L. Warshaw, MD, FACS Will Chapleau, RN, EMT-P Tucson, AZ VICE-CHAIR Boston, MA Director CHAIR Daniel L. Dent, MD, FACS DIVISION OF RESEARCH AND Marshall Z. Schwartz, MD, FACS San Antonio, TX OPTIMAL PATIENT CARE Philadelphia, PA SECRETARY Clifford Y. Ko, MD, VICE-CHAIR Executive Staff Terry L. Buchmiller, MD, FACS MS, MSHS, FACS Anthony Atala, MD, FACS EXECUTIVE DIRECTOR Director Boston, MA David B. Hoyt, MD, FACS Winston-Salem, NC David P. Winchester, MD, FACS Therese M. Duane, MD, DIVISION OF ADVOCACY John L. D. Atkinson, MD, FACS MBA, CPE, FACS, FCCM Medical Director, Cancer Rochester, MN AND HEALTH POLICY Fort Worth, TX Frank G. Opelka, MD, FACS Michael F. Rotondo, MD, FACS James C. Denneny III, MD, FACS Nicole S. Gibran, MD, FACS Medical Director, Quality Medical Director, Trauma Alexandria, VA Seattle, WA and Health Policy Margaret M. Dunn, MD, FACS David A. Spain, MD, FACS Patrick V. Bailey, MD, FACS Dayton, OH Stanford, CA Medical Director, Advocacy Timothy J. Eberlein, MD, FACS David J. Welsh, MD, FACS Christian Shalgian St. Louis, MO Batesville, IN Director

V103 No 2 BULLETIN American College of Surgeons Author bios*

*Titles and locations current at the time articles were submitted for publication.

a b c

d e | 5

f g h

DR. ANDERSON (a) is a retired pediatric DR. AVERBOOK (c) is professor of DR. BOUGHEY (e) is professor of surgery surgeon and was the first woman surgery, general medical sciences and vice-chair, research, department of President of the American College (oncology) and dermatology, MetroHealth surgery, Mayo Clinic, Rochester, MN. of Surgeons (ACS) (2005−2006). Medical Center, Cleveland, OH; and She is Chair, ACS Clinical Research Vice-Chair, Commission on Cancer Program (CRP) Education Committee. DR. ARBOLEDA-OSORIO (b) is a general (CoC) Accreditation Committee. surgeon dedicated to breast oncology, DR. BRILL (f) is chief resident, HIMA-San Pablo Hospital System, DR. BEDROSIAN (d) is professor, general surgery, Naval Medical Caguas, Puerto Rico, and President, department of breast surgical oncology, Center, San Diego, CA. Puerto Rico Chapter of the ACS. and medical director, Nellie B. Connally Breast Center, University of Texas MD MS. BURA (g) is Associate Director, ACS Anderson Cancer Center, Houston. She Division of Member Services, Chicago, IL. is Co-Chair, Prevention Committee, MR. CARMODY Alliance for Clinical Trials in Oncology. (h) is Government Affairs Coordinator, ACS Division of Advocacy and Health Policy, Washington, DC. continued on next page

FEB 2018 BULLETIN American College of Surgeons Author bios continued

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n o

DR. COMPTON (i) is professor of life DR. DICKSON-WITMER (k) is medical MS. FOE (m) is Regulatory Associate, ACS sciences, Arizona State University, Tempe; director, Christiana Care Breast Center Division of Advocacy and Health Policy. professor of laboratory medicine and and Breast Program and Helen F. Graham pathology, Mayo Clinic School of Medicine, Cancer Center and Research Institute, MR. FRANKEL (n) is Manager, International Scottsdale, AZ; chief medical officer, Newark, DE; and clinical assistant professor Chapters and Special Initiatives, ACS National Biomarker Development Alliance, of surgery, Thomas Jefferson University Division of Member Services. Scottsdale; and chair, preanalytics for Sidney Kimmel College of Medicine, DR. HARRISON precision medicine project team, College Philadelphia, PA. She is Vice-Chair, ACS (o) is an obstetrician/ of American Pathologists, Northfield, IL. CRP Dissemination and Implementation gynecologist, Kaiser Permanente Committee, and CoC Delaware State Chair. San Diego Medical Center, CA. DR. DEGNIM (j) is Joe M. & Ruth continued on next page Roberts Professor of Surgery, department DR. FANTUS (l) is vice-chairman, of surgery, Mayo Clinic, Rochester, department of surgery; medical director, MN. She is co-leader, Women’s Cancer trauma services; and chief, section of surgical Program, Mayo Clinic, and leads research critical care, Advocate Illinois Masonic related to high-risk breast lesions. Medical Center, Chicago, IL. He is clinical professor of surgery, University of Illinois College of Medicine, Chicago, and Past- Chair, ad hoc Trauma Registry Advisory Committee, ACS Committee on Trauma.

V103 No 2 BULLETIN American College of Surgeons Author bios continued

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u v w

DR. IGNACIO (p) is program director, MR. MOREAU (s) is Manager, DR. PELLEGRINI (u) is chief medical general surgery, Naval Medical Center. Domestic Chapter Services, ACS officer, UW Medicine, and vice-president for Division of Member Services. medical affairs, University of Washington, DR. MARTIN (q) is a general surgery Seattle. He is a Past-President of the ACS. resident, department of surgery, MS. OEHMEN (t) is ACS Professional University of Virginia, Charlottesville, Association-SurgeonsPAC and MR. PEREGRIN (v) is Senior Editor, and a Resident Member of the ACS. Grassroots Manager, ACS Division Bulletin of the American College of of Advocacy and Health Policy. Surgeons, ACS Division of Integrated MS. McDONALD (r) is Legislative and Communications, Chicago, IL. Political Affairs Manager, ACS Division of Advocacy and Health Policy. DR. SISE (w) is chief of staff, department of surgery, Scripps Mercy Hospital, San Diego, CA.

FEB 2018 BULLETIN American College of Surgeons EXECUTIVE DIRECTOR’S REPORT

Looking forward

by David B. Hoyt, MD, FACS

he American College of Surgeons (ACS) online share their common interests. The communities have community platform, ACS Communities, recently become an important part of our culture. Tbegan its fourth year. Under the leadership of Tyler The total number of communities as of December 1, G. Hughes, MD, FACS, Editor-in-Chief, the communi- 2017, was 115, of which 76 were open and 39 were ties have become one of the most popular benefits of closed. (Open communities are accessible to all mem- membership in the College, and the network continues bers of the ACS, and closed communities exist primar- to grow both in terms of number of communities and ily to provide online work forums for ACS governing member engagement. bodies and committees.) The five most active communities were the General Surgery, Rural Surgery, Breast Surgery, Minimally Invasive Surgery, and Bariatric An ancient concept Surgery Communities. By far the most widely used The communities, in many ways, fill a basic human community was the General Surgery Community, need to use communication to foster the survival and with 22,239 members, 1,468 total discussion posts, 111 evolution of social groups. Communication as a means new threads, 1,357 replies to discussions, and 208 re- of promoting civilization dates back around 70,000 to plies to sender. 30,000 years ago, during what historian Yuval Noah All of the volunteer editors have done a great job Harari, PhD, refers to as the Cognitive Revolution. It of developing their communities, and I want to thank 8 | is believed that at this time accidental genetic muta- them all for their hard work and commitment. The tions changed the inner wiring of the brains of sapiens, Breast and Colon and Rectal Communities are both ac- enabling them to think in unprecedented ways and to tive, with a lively exchange of clinical and nonclinical share information that extended beyond offering warn- posts. Editors Mike Stark, MD, FACS, of the Endocrine ings of imminent danger and pointing to the location Community and Don Nakayama, MD, FACS, of the of food, for example. Early man was now able to make History Community (which now has 700 members) logical connections, engage in social interactions, and have done a phenomenal job of growing their commu- to transmit information about more complex subjects.* nities and encouraging meaningful dialogue. With this new ability, humans developed and The members of the Women in Surgery Commu- shared legends, myths, and religions within their own nity have succeeded in addressing both clinical and social groups. This ability to tell stories and find mean- nonclinical matters in a professional manner. The Sur- ing in them served as the basis of shared cultural mores geons as Writers Community is relatively small but needed to bond members of communities. The broad provides great help to surgeons who write both for consequences of this evolution included the ability professional and personal reasons. to plan and execute complex actions; establish larger, Some frequent posters have developed an inter- more cohesive social groups; and innovate by apply- national reputation. For example, Patrick Molt, MD, ing the group’s collective intelligence.* FACS, a general surgeon from Fairfield, IL, and Mark Crabbe, MD, FACS, a general surgeon from Sumter, SC, are respected commenters because their remarks A popular form of communication and advice are rooted in scientific evidence and clini- For the last few years, many members of the College cal experience. have found that the ACS Communities provide a valuable means of tapping into the collective intelligence of their peers to address challenges they face in treating The ACS Communities are for everyone difficult cases, learn about innovative practices, and Some contributors, however, seem to believe the ACS *Harari YN. Sapiens: A Brief History of Humankind. New York, NY: leadership is not listening to them or is too focused HarperCollins Publishers; 2015. on certain surgeons at the expense of others, and stri-

V103 No 2 BULLETIN American College of Surgeons EXECUTIVE DIRECTOR’S REPORT

For the last few years, many members of the College have found that the ACS Communities provide a valuable means of tapping into the collective intelligence of their peers to address challenges they face in treating difficult cases, learn about innovative practices, and share their common interests.

dently voice their discontent in the communities. I can Advocacy Community rather than in the General Sur- assure you that many College leaders, myself included, gery Community. The surgeons and staff who read follow the communities regularly to get a better feel posts in the Advocacy Community are more likely to for the issues that are of greatest concern to surgeons share your frustrations and are focused on resolving in the trenches. This feedback gives us firsthand in- these challenges, whereas the members of the Gen- sights into the matters on which we need to take a eral Surgery Community may be more interested in stand or offer professional counsel. getting advice about clinical matters. While we value thoughtful critiques from our col- The ACS Communities platform provides a valu- leagues, it can be discouraging when a few individu- able means of telling stories that allow us to reinforce als choose to vent their frustrations without offering our principles as a professional society, to learn from or acknowledging any solutions. I understand that each other, and to arrive at evidence-based solutions some members of the communities read the digests to problems, both clinical and nonclinical. All mem- | 9 regularly and enjoy seeing someone offer the same bers of this organization are encouraged to participate advice they would give, but are hesitant to offer their in this powerful tool that can bring us together and own posts. I believe that some people may be reticent promote our cultural values. ♦ to comment because they would prefer to avoid an online debate that leads nowhere. If you are among the individuals who have been resistant to post, I invite you to post once to see how easy it is, even if only to introduce yourself and let others know you find their posts beneficial. To those few individuals who may view the communities as an outlet for airing their grievances, certainly I encourage you to speak your mind about how the College could better serve its members and represent your interests. But at the same time, I would remind these posters to tap into their emotional intelligence and consider whether their remarks are fostering a healthy dialogue about the issues or are driving people away. Are they sharing important information and offering innovative solutions to the challenges surgeons are facing? Are they encouraging other surgeons to add their perspective so that we can creatively and collectively improve surgeons’ ability to provide quality care? I would also recommend that contributors post in the community that is focused on their concerns. For instance, if legislative and regulatory issues are If you have comments or suggestions about this or other issues, please topping your list of priorities, consider posting in the send them to Dr. Hoyt at [email protected].

FEB 2018 BULLETIN American College of Surgeons HURRICANE PREPARATION: LESSONS LEARNED

10 |

Preparation, teamwork pay off during 2017 Atlantic hurricane season

by Tony Peregrin

V103 No 2 BULLETIN American College of Surgeons HURRICANE PREPARATION: LESSONS LEARNED

wo Category 4 Atlantic storms made landfall Carolyn Bookout Presidential Endowed Chair, and in the mainland U.S. in the same two-week chair, department of surgery, Houston Methodist Hos- Tperiod of late summer 2017, making Hurricane pital, TX. “This planning is done as a routine part of Harvey and Hurricane Irma back-to-back disasters living in this area, which is not infrequently hit with that challenged surgeons’ preparedness and capacity hurricanes and flooding due to tropical storms with to provide adequate patient care.1,2 exceptionally heavy rain.” Hurricane Harvey hit southeastern Texas August “Once we knew it was in the Gulf and that there 25, 2017, resulting in more than 75 deaths.3 Hurricane was a possibility that Houston would be impacted, we Irma made landfall September 10, 2017, on Florida’s didn’t wait for landfall,” said SreyRam Kuy, MD, MHS, western coast, resulting in 75 deaths, including 14 FACS, associate chief of staff, Michael E. DeBakey Vet- storm-related deaths in the Florida Keys and 11 seniors erans Affairs (VA) Medical Center. “Figuring out the who perished in a Hollywood, FL, nursing home.4 Esti- logistics is a huge part of disaster preparation. I think, mates for damages resulting from Hurricane Harvey as surgeons, we sometimes forget all the other stuff range from $65 billion to $190 billion, while Hurricane that happens outside of the operating room (OR). We Irma damage could end up costing between $50 billion think the OR is the coolest part and the most fun part, to $100 billion.5 but so much happens elsewhere, everything from On September 18, 2017, Hurricane Maria made land- waste management to food services to the electricity fall in Puerto Rico (see related story, page 18). In all, and plumbing.” the three storms resulted in more than 260 deaths and When Harvey transformed from a tropical storm | 11 an estimated $300 billion in damages—making the to a Category 4 hurricane, it became apparent that hos- 2017 Atlantic hurricane season the costliest on record.6 pital staffing needs could reach critical levels. According to CNN, “each hurricane posed different “We knew that if we let people go home, there was threats and caused different problems. Harvey brought a risk that they wouldn’t be able to get back in—and massive flooding, Irma deadly storm surges, and Maria that’s exactly what happened,” Dr. Kuy said. “Hol- catastrophic high winds.”7 combe Boulevard, which runs through the Texas This article describes how surgeons and their insti- Medical Center, became a river, and all the streets tutions prepared for the storms, surgeons’ efforts to were flooded. People who had left the hospital couldn’t serve patients during the storms, the value of disaster physically drive through.” To reach the hospital, “they preparedness, and lessons learned from working in the swam or waded through the water, which many of our trenches during Hurricanes Harvey and Irma. staff, residents, and students did.” According to Dr. Kuy, nearly 700 staff members remained at the DeBakey VA Medical Center in prep- Hospital preparation aration for Harvey, some sleeping on office floors, “All of the hospitals in Houston learned a lot from with many others sleeping on cots in the facility’s their experience with Tropical Storm Allison,” said auditorium. Barbara L. Bass, MD, FACS, FRCS(Hon), President, Even as an estimated 60 inches of rain fell from American College of Surgeons (ACS), referring to the Hurricane Harvey in Texas, upending previous U.S. tropical storm that devastated southeast Texas in June storm records, many hospitals in the area, such as 2001 due to a record amount of flooding. “Hospitals Texas Children’s Hospital, remained self-reliant in realized that every facility needs to have its own prep- terms of staffing.8 aration plan in place well before one of these events “We basically had all our people in place,” said happens. At our institution, we have a well-developed Mary L. Brandt, MD, FACS, an attending surgeon, plan that includes a ride-out team that designates, well pediatric surgery service, Texas Children’s Hospi- in advance, who is going to be at the hospital at the tal, pointing to the hospital’s ride-out system as the time of the incident,” said Dr. Bass, the John F. and reason physicians were on hand throughout the

FEB 2018 BULLETIN American College of Surgeons HURRICANE PREPARATION: LESSONS LEARNED

Scenes outside Texas Children’s Hospital in the wake of Hurricane Harvey Houston Methodist Hospital ride-out team

storm. “If you’re on the ride-out team, you know “On Saturday, it started raining, and by Sunday that you’re there until it’s over.” morning, I was following through with the intensive care unit (ICU) to make sure we had people there,” said Dr. Ochoa, the surgical director of the surgical Leading by example: Do as I do and liver ICU. “By early morning, we realized how Staff, including physicians, adopted new roles during bad it was and that our staff wasn’t going to be able to Harvey in an effort to keep hospital operations up and get in. We had two interns and a second-year resident, running. a nurse practitioner (NP), and 28 sick ICU patients,” 12 | “The nurses and physicians worked together to Dr. Ochoa said. “I live about three miles away [from figure out what needed to be done,” Dr. Brandt said. the hospital]. I drove about a mile, which was as close “There were physicians doing tasks they don’t usually as I could get to the hospital, and I waded in through do. There was no question everybody was just chipping waist-deep water the rest of the way—about a mile and in wherever they could to help make things as easy as a half. The three residents who made it all had to basi- possible for everybody else. As a result, there was an cally do what I did to make it in. One of them walked extraordinary camaraderie.” about a mile or so with water up to his chest at some “We had staff who were here five or six days without points to get in. And one of them had his car stall out ever going home—and that was the same for leader- on the way in, and he left it there and continued to ship,” added Dr. Kuy. “We’d been in the hospital for walk about another three-quarters of a mile to get in.” the same amount of time, sleeping in the same gross, To make matters more dire, many of the staff who disgusting scrubs and the same pair of socks. I think were working at the hospital during the storm had to the fact that the staff saw us going through the same leave family and loved ones at home to face the hurri- situation had a huge impact on them. You have to show cane alone, including Dr. Ochoa, who has a wife and people that you are in it with them.” three children. Surgeons who led by example included not only “Leaving my house, I was a little bit anxiety-ridden those individuals willing to work in the trenches and because I wasn’t quite sure if I would be able to get take on new tasks, but also those health care profes- home if something were to happen, but I also knew sionals who demonstrated a commitment to caring for that I had a couple of residents and an NP [at the hos- patients under extraordinary circumstances. pital] and the patients, and somebody had to take care “On Sunday morning, it became really clear that of them. So, that’s why I decided to find a way to get [Houston Methodist Hospital] was an island and that here—to guide my residents and to give them support. people were having a really hard time getting to and And to support the nurses who also were here, and from the medical center,” said Dr. Bass. “One of our really just make sure that our patients were going to surgeons, Robert Ochoa, Jr., MD, FACS, who lives be safe,” Dr. Ochoa said. nearby, actually walked in, almost swam in through Another surgeon undeterred by the flooding was deep water to work.” Stephen Kimmel, MD, FACS, a pediatric surgeon who

V103 No 2 BULLETIN American College of Surgeons HURRICANE PREPARATION: LESSONS LEARNED

Houston Methodist Hospital ER team Roberta Schwartz, executive vice- Houston Methodist Hospital patient care unit staff president, Houston Methodist Hospital, delivering meals to staff

traveled by canoe to Clear Lake Regional Medical Center, Webster, TX, to operate on a 16-year-old suffering from testicular torsion.9 “I got the call to go take care of this boy and I drove my car about a mile from my house but the water was getting pretty deep, so I thought I would get stuck,” Dr. Kimmel said. “I turned around and went back to the house and called my chief medical officer [CMO] and said, ‘I can do the surgery, but I | 13 can’t get there. I need your help.’” Dr. Kimmel’s CMO made some phone calls and eventually was able to Texas Children’s Hospital acute care team connect Dr. Kimmel with the Dickinson Volunteer Fire Department. Firemen showed up at Dr. Kimmel’s house at approximately 1:30 am. “At my door were two 19-year-old guys soaked to the skin in firefighter base- ball caps. They said, ‘Okay, doc, we’re going to run for a while,’” Dr. Kimmel said. “We ran about a half a mile down my street, and it was dark and windy and pouring rain. We got out to one of the main roads and ran a little bit further to the fire station, and that’s where they had stashed the canoe because the water between the station and the interstate was Houston Methodist Hospital dialysis team pretty deep. The three of us paddled about half a mile to the Interstate 45 overpass in Dickinson.” One of the volunteer firefighters had parked an F30 truck under the overpass. They loaded the canoe into the truck and were able to get through the feeder ramp and onto the highway, which had flooding but was passable, according to Dr. Kimmel. At another feeder road, the three men faced a flooded road that was not passable, so they parked the truck, jumped back into the canoe, and paddled up the feeder, passing people who were standing on top of their cars Texas Children’s Hospital support staff waiting for help.

FEB 2018 BULLETIN American College of Surgeons HURRICANE PREPARATION: LESSONS LEARNED

Black Hawk helicopter delivering a pediatric patient to a dialysis center

Dr. Kimmel said the deepest water he encountered patients enough credit. It takes so much courage and that day was located directly in front of the hospital. resilience to do that. When a patient says, ‘I know I “It was probably five feet deep. The hospital is located can count on you. As long as I can get there, I know a little bit higher, so we were able to climb up onto the you will take care of me,’ that is something we cannot embankment and make our way to the OR,” he said. take lightly. That is a huge responsibility for us to live “I really had no idea how bad it was going to be. I’d up to that expectation. I’m so proud of all my staff at been in the hospital earlier that day and done rounds the Michael E. DeBakey VA Hospital because they and done surgery and came home, and I was pretty lived up to that. The surgeon who performed his sur- 14 | confident that if I had to go back anytime, it would be gery was at a flooded apartment. We were able to get no problem,” said Dr. Kimmel. a high-water vehicle to bring her in so that she could When Dr. Kimmel entered the hospital for the do the surgery,” said Dr. Kuy. second time that day, he found the OR staff fully prepped to begin the procedure. The hour-long operation was a success, and the patient was discharged Patient care: Chronic medical conditions within 48 hours. and pediatric patients in need of dialysis Some patients displayed as much grit as the medical As Harvey continued to swirl through the Gulf of teams who cared for them. A former U.S. Army Ranger Mexico toward the Texas coastline, surgeons and hos- swam through flood waters to the DeBakey VA Medi- pital systems, particularly in the southeastern part of cal Center, where he was treated for a burst appendix. the state, put their ride-out teams and other disaster According to Dr. Kuy, when the patient couldn’t get plans into motion. anyone to take him to a hospital, he printed out a map “We anticipated as many discharges as possible in to the VA, which he enclosed in a clear plastic garbage order to get everybody out of the house that we could bag to waterproof it, and he walked to the hospital, possibly get out of house,” Dr. Bass said. “We, of course, even as the water rose past his knees and then up to shut down anything but emergency surgery, but we did his chest. have a few emergency cases that needed to be done, “This Army Ranger swam through two miles of including abdominal emergencies and things like per- sewage-contaminated flood waters to get to the hos- forated bowel with peritonitis. The kind of medical pital,” said Dr. Kuy. “I asked him, ‘How did you know emergencies that began to evolve over the next three it was contaminated with sewage?’ He said, ‘It smelled to four days were primarily the medical patients who like a latrine. You never forget the smell of a latrine.’” had chronic conditions, such as people who needed The patient was confident that if he was able to help with their diabetes or others with heart failure.” make it to DeBakey, he would receive proper care. Managing chronic conditions was a top priority at He said, ‘I knew that if I could get to the VA, they Texas Children’s Hospital as well. would take care of me. I knew that I could call on the The chief of pediatric nephrology, Michael Braun, VA,’” Dr. Kuy said. “It’s humbling. We don’t give our MD, realized that dozens of children had gone several

V103 No 2 BULLETIN American College of Surgeons HURRICANE PREPARATION: LESSONS LEARNED

Houston Methodist Hospital pharmacy with all hands on deck days without dialysis, according to Dr. Brandt. “He Preparing for Irma called a colleague, Rita Swinford, MD, who is the “We knew what to expect mostly due to Katrina and medical director of the pediatric unit at Children’s previous hurricanes. We knew that there would be Memorial Hermann Hospital located a few blocks virtually nothing going on during the hurricane itself, away, and the two of them worked with the U. S. but we wanted to have a significant number of staff Coast Guard to help find these children—33 in all,” ready after the hurricane passed,” Dr. Ginzburg said. said Dr. Brandt, noting that these two hospitals cared As a result, Jackson South Medical Center organized for virtually every child on dialysis in southeast staff into teams. The Alpha team would be present Texas.10 “There were Black Hawk helicopters deliv- during the hurricane, and the Bravo team would be | 15 ering these children to dialysis centers—including available after Irma passed. our center—efforts that saved these young patients’ Part of Jackson South Medical Center’s natural lives,” Dr. Brandt said. disaster planning also took into account staff morale. “Our administrators are excellent. They basically allowed immediate family members to come in with Hurricane Irma the physicians with organized places for them to stay. Less than two weeks after Hurricane Harvey made And, although family members were asked to bring landfall, Hurricane Irma trounced South Flor- in their own provisions, the hospital actually provided ida, Georgia, and the Caribbean. After hitting the food for everyone,” he said. In fact, significant changes Florida Keys as a Category 4 hurricane, the storm in designated evacuation zones meant more individu- was eventually downgraded to a Category 1 as it als came into the center than originally anticipated. pushed inland and moved up through the middle Jackson South Medical Center provided 6,500 meals of the state, bringing heavy rain and strong winds within a period of two days. to areas of Florida that were not initially expecting Sheev Dattani, MD, a Resident Member of the ACS these conditions.11,12 who is affiliated with Florida Hospital, Tampa, said his Enrique Ginzburg, MD, FACS, trauma medical facility prepared four OR teams and a fully staffed ER director and vice-chair of surgery, Jackson South to provide care to victims of the storm. However, the Medical Center and Chair, Florida Board of Medi- downgraded storm didn’t result in a noticeable bump cine, said his experiences overcoming the challenges in trauma patients, according to Dr. Dattani. of the catastrophic earthquake that struck Haiti in “Fortunately, it was different for us in Tampa 2010 prepared him for Irma.13 because the hurricane missed us, although we had Jackson South Medical Center is one of two safety- initially thought we were going to get a direct hit,” net hospitals for Dade County, Dr. Ginzburg said. Dr. Dattani said. “We ended up being the front line to the Florida Keys, Originally from Saskatoon, Saskatchewan, the tropi- so we received the most significant number of patients cal hurricane was the young surgeon’s first experience right after the hurricane passed through,” he said. with how a hospital engages in hurricane prep. In a

FEB 2018 BULLETIN American College of Surgeons HURRICANE PREPARATION: LESSONS LEARNED

Portable cots set up in the auditorium in Michael Michael E. DeBakey VA Medical Center: Dr. Kuy E. DeBakey VA Medical Center (foreground) with surgery residents who stayed on site during Hurricane Harvey and continued training

REFERENCES report to CBC News, a Canadian news outlet, Dr. Dat- 1. Cummins E. Irma may have been the bigger storm, but tani said, “I’m grateful for my medical training and the damage from Harvey’s storm surge will last for years. I’m grateful for being able to support whoever I can Slate.com. September 13, 2017. Available at: www.slate.com/ here.”14 Dr. Dattani is Advanced Trauma Life Sup- articles/health_and_science/science/2017/09/reporters_ port® (ATLS®)-certified and an ATLS instructor. “I compare_harvey_and_irma_s_impacts.html. Accessed have found this training useful, specifically regard- November 1, 2017. 2. Lam L. What has made this hurricane season remarkable so ing how to quickly triage multiple trauma patients, far. The Weather Company, LLC/Weather.com. Available so I felt ready to help in any situation that we would 16 | at: https://weather.com/storms/hurricane/news/2017- potentially see.” atlantic-hurricane-season-records-notables. Accessed November 1, 2017. 3. George C, Kadifa M, Ellis L, Blakinger K. Storm deaths: Harvey claims lives of more than 75 in Texas. Houston Lessons learned Chronicle. October 9, 2017. Available at: www.chron.com/ While physicians who cared for patients during both news/houston-weather/hurricaneharvey/article/Harvey- Hurricane Harvey and Hurricane Irma credit their Aftermath-Houston-police-officer-dies-19-12159139.php. individual institutions’ disaster preparedness as key Accessed November 1, 2017. to meeting the challenges of these storms, many high- 4. Rabin C. Unofficial death toll from Hurricane Irma now stands at 75 across the state. Miami Herald. September 23, lighted areas for possible improvement. 2017. Available at: www.miamiherald.com/news/weather/ “We ran out of food,” said Dr. Kuy. “How are you hurricane/article175029276.html. Accessed November 1, going to run a hospital if you can’t even provide food? 2017. The VA system usually requires lots of contracts and 5. Donnelly G. Hurricane Irma and Harvey damaged 1 million a lot of processes to make things happen. We reached cars. What happens now? Fortune.com. September 20, 2017. Available at: http://fortune.com/2017/09/20/hurricane- out to Secretary David J. Shulkin [U.S. Veterans Affairs irma-harvey-damaged-cars/. Accessed November 3, 2017. office], who was amazing—he made it happen. By 6. Jervis R. Harvey, Irma, Maria: Different disasters, different midnight on Monday, we had a convoy of high-water recovery. USAToday.com. October 28, 2017. Available at: trucks that brought in food for us. That had a huge www.usatoday.com/story/news/2017/10/27/harvey-irma- impact because it showed that the national leadership maria-different-disasters-different-recovery/807485001/. Accessed November 3, 2017. really cared deeply about staff and patient well-being.” 7. Levenson E. 3 Storms, 3 responses: Comparing Harvey, Another area for improvement is waste manage- Irma, and Maria. CNN.com. September 27, 2017. Available ment. “We don’t actually have a system for taking at: www.cnn.com/2017/09/26/us/response-harvey-irma- care of the waste ourselves. We had about three maria/index.html. Accessed November 3, 2017. days’ worth of space for waste even after emptying continued on next page it out,” Dr. Kuy said. “Clearly, we were flooded for at least three days. We need to think proactively about how we can prepare for this and how we can deal with waste management on our own.” Despite these

V103 No 2 BULLETIN American College of Surgeons HURRICANE PREPARATION: LESSONS LEARNED

Dr. Dattani (right) with Allen Chudzinski, MD, FACS, at Florida Hospital just before Hurricane Irma hit Post-Hurricane Irma devastation challenges, Dr. Kuy said strong leadership enabled REFERENCES, CONTINUED hospital staff to provide quality patient care. 8. Samenow J. 60 inches of rain fell from Hurricane Harvey Dr. Ginzburg said a valuable lesson learned at Jack- in Texas, shattering U.S. storm record. Washington Post. son South Medical Center was to have both the Bravo September 29, 2017. Available at: www.washingtonpost. team—the recovery team intended to provide services com/news/capital-weather-gang/wp/2017/08/29/harvey- marks-the-most-extreme-rain-event-in-u-s-history/?utm_ after the storm had passed—already in-house along term=.88dc0b02b78b. Accessed November 3, 2017. with the Alpha team. Physicians—many of whom 9. University of Houston. Houston physician canoes to were victims themselves suffering the loss of prop- hospital to perform surgery. Houston Public Media. erty due to Irma—worked tirelessly over multiple Press release. August 29, 2017. Available at: www. | 17 days to treat patients and to keep their institutions up houstonpublicmedia.org/articles/news/2017/08/29/233769/ houston-physician-canoes-to-hospital-to-perform-surgery/. and running. Even with adequate staffing and ride- Accessed November 3, 2017. out plans in place, health care professionals fought 10. Jeltsen M, Campbell A. Inside the ‘impossible’ mission through physical and emotional exhaustion. to rescue 33 kids desperate for dialysis during Harvey. “With Irma, some people worked for two-and-one- Huffington Post.September 1, 2017. Available at: www. half days at the hospital without relief,” Dr. Ginzburg huffingtonpost.com/entry/inside-the-rescue-mission- of-33-children-in-need-of-dialysis-during-harvey_ noted. us_59a8e389e4b0b5e530fd8beb. Accessed November 3, 2017. No matter how prepared hospitals are to meet the 11. Storm’s winds begin battering Tampa Bay area. New York challenges of natural disasters, it’s the enduring spirit Times. September 10, 2017. Available at: www.nytimes. of the health care providers—through coordinated com/2017/09/10/us/hurricane-irma-florida.html?_r=0. teamwork, open communication, and a willingness Accessed November 3, 2017. 12. Ferris R, Shaffer L. Hurricane Irma weakens to Category to take on new tasks—that results in the provision of 1 as it heads to Florida’s interior, but remains dangerous. care to patients in need. CNBC. September 11, 2017. Available at: www.cnbc. “It’s interesting—when you are aware that you com/2017/09/10/hurricane-irma-heads-toward-fort-myers- are involved in a real emergency, people actually continuing-vicious-ride-up-floridas-coast.html. Accessed rally,” Dr. Bass said. “They take on a sense of a spe- November 1, 2017. 13. Ginzburg E, Goodman C, Sussman G, Klein Y. UM Ryder cial mission. Situations like these actually become a Trauma Center/Israel fellowship program provides a model memorable event, a bonding event for those people for global trauma training. Bull Am Col Surg. April 2017. that are thrown into a crisis together.” ♦ Available at: bulletin.facs.org/2017/04/um-ryder-trauma- center-israel-fellowship-program-provides-model-global- trauma-training/. Accessed November 1, 2017. 14. Soloducha A. Saskatoon doctor prepares to treat hurricane Acknowledgments victims in Florida. CBC News. September 10, 2017. The photos accompanying this article were supplied by Available at: www.cbc.ca/news/canada/saskatchewan/ the interviewees. saskatoon-doctor-prepares-to-treat-hurricane-victims-in- florida-1.4283383. Accessed November 1, 2017.

FEB 2018 BULLETIN American College of Surgeons SURGEONS RESPOND IN PUERTO RICO

18 |

From the rescuers to the rescued: A tale of two hurricanes

by Bolívar Arboleda-Osorio, MD, FACS

V103 No 2 BULLETIN American College of Surgeons SURGEONS RESPOND IN PUERTO RICO

Expressway leading from Caguas to San Juan blocked by trees, electrical wires, and posts

Editor’s note: On September 6, 2017, Hurricane Irma ripped the Caribbean Sea. While the eye of this super storm through a string of small Caribbean islands, with the eye was projected to pass through Puerto Rico, most of the passing over Barbuda, damaging approximately 95 per- winds stayed to the north, and it felt more like the tropi- cent of the buildings on the island. Surgeons from nearby cal storms to which islanders had grown accustomed. Puerto Rico rushed to the rescue. Two weeks later, on Sep- The northern Lesser Antilles, however, did not fare as | 19 tember 20, Hurricane Maria made landfall in Puerto Rico, well. Islands like Barbuda experienced 95 percent dev- devastating the U.S. commonwealth and killing 499 people. astation to all infrastructure, and for the first time in This article recounts surgeons’ efforts to respond to both more than 300 years, no human inhabitants remained natural disasters. on the island after the permanent evacuations. Caribbean people, however, are resilient. For as long he roar of the turboprop engine faded as Ramón as can be recounted in written and verbal tales, the K. Sotomayor, MD, FACS, a general surgeon and region suffers an economic setback each time a big Tsurgical oncologist, was preparing to disembark storm passes through. Unlike large developed nations, from the plane. He was among a group that included the smaller islands have limited disaster recovery funds one surgeon, one emergency room physician, and and even more limited crisis and emergency manage- one intensive care unit physician assembled through ment plans—but in the words of a past-Prime Minister an initiative of the HIMA-San Pablo Hospital System, of Barbados, “It is the special character of a people who Caguas, Puerto Rico, to assist in the aftermath of have survived and risen above slavery and indenture- Hurricane Irma, which devastated the islands of St. ship, racism and the exploitation of colonization, and Thomas, Tortola, Barbuda, and a number of other limited economic resources.”* Virgin Islands just a few days earlier. As soon as the storm left the region, medical teams from Puerto Rico were on the move to aid their island brothers and sisters. “As the plane banked over the Hurricane Irma island, it was heartbreaking to see,” said Dr. Sotomayor, Hurricane Irma moved over the northern Caribbean who has treated patients in the British Virgin Islands in early September as the strongest Atlantic basin hur- through a collaborative partnership. “I had seen the ricane ever recorded outside the Gulf of Mexico and islands many times from the air before, but this time it was different. The usual lush greenery was missing. *Caricom.com. Resilience of Caribbean people will determine suc- One of the main clinics on the island of Bougainville cess or failure—former PM Arthur. March 27, 2015. Available at: http:// caricom.org/communications/view/resilience-of-caribbean-people-will- was destroyed and the other one, Peebles Hospital, was determine-success-or-failure-former-pm. Accessed December 18, 2017. running on a generator.” One of the local surgeons,

FEB 2018 BULLETIN American College of Surgeons SURGEONS RESPOND IN PUERTO RICO

Fallen trees and electrical wires blocking the expressway entrance

Marjorie Yee-Sing, MB, BS, FACS, who has practiced was minimal, and no flights were leaving the island. in Tortola for some time, introduced Dr. Sotomayor to After a week in the intensive care unit, the patient a number of patients. After reviewing their charts and started recovering. It wasn’t until more than a week examining them, he decided to airlift two of them for later she was able to communicate and finally under- care at a tertiary center in Caguas. stood what happened and why she was in HIMA-San 20 | Meanwhile, in Puerto Rico, Bolívar Arboleda- Pablo Hospital. Osorio, MD, FACS, the author of this article, was taking What is unfortunate about this story is that during care of a 74-year-old woman who had been flown in her recovery, a second storm—Hurricane Maria, a from St. Thomas. When she arrived in the emergency deadly Category 5 storm—directly hit the island of room (ER), she was noncommunicative. Initially, the Puerto Rico. ER team thought a neurologic baseline condition could be part of the problem because she arrived without relatives or a copy of her records from St. Thomas, but Hurricane Maria after ruling out any anatomic neurologic problem, we Hurricane Maria roared mightily in the early hours of proceeded with her surgical care. Wednesday, September 20, 2017. Having experienced We knew she had abdominal pain for a week prior Hurricanes Frederic (1979—Category 4), Hugo (1989— to her transfer to Puerto Rico. A computed tomogra- Category 5), Marilyn (1995—Category 3), Hortense phy scan revealed a major process in her ascending (1996—Category 4), Georges (1998—Category 4), and colon, and we proceeded with an exploratory laparot- many others in the past five decades, the 3.4 million omy. Intraoperative findings revealed the patient had residents of the Commonwealth of Puerto Rico thought necrosis of the posterior wall of the ascending colon, they were adequately prepared with plywood, storm and a right colectomy with ileotransverse anastomosis shutters, water, and batteries. With sustained winds of was performed. 155 miles per hour, the monster hurricane tore through The hardest part was being unable to communicate the southeastern coast as it traversed the island. No with the patient or any relative. I managed to talk to other hurricane had had similar wind force since Hur- her sister-in-law once via a military phone to explain ricane Okeechobee (locally known as Huracán San her condition, but communication from St. Thomas Felipe) in 1928.† †Fritz A. Puerto Rico has a long history with tropical storms. None of On Thursday, September 21, the whole land- them were like Hurricane Maria. Washington Post. September 19, 2017. scape had changed for the island of Puerto Rico. The Available at: www.washingtonpost.com/news/capital-weather-gang/ El Yunque—the only tropical rainforest in the U.S. wp/2017/09/19/puerto-rico-has-a-long-history-with-tropical-storms- none-of-them-were-like-hurricane-maria/?utm_term=.ee0a11ee3c1c. National Forest System—looked like a barren land- Accessed December 18, 2017. scape, much like an early winter scene in New England

V103 No 2 BULLETIN American College of Surgeons SURGEONS RESPOND IN PUERTO RICO

Group of volunteers from HIMA-San Pablo Caguas Hospital preparing supplies after Hurricane Irma when the trees are bare, waiting for the first snow. The home care centers, and other smaller health care facili- majestic, weather-beaten fort of El Morro, however, ties have closed as well. This is something I had never survived mostly unscathed, keeping true to its purpose, experienced in my 34 years as a physician. Our hospi- in my observation, of defending the Spanish port city tal was overloaded with patients who were transferred of San Juan from enemies. in from other institutions that fared worse than us. The more modern buildings in San Juan, as well The OR was back to nearly fully functional status by | 21 as the electrical and communication systems of the the beginning of October, but the number of emer- island, were decimated. More than 80 percent of the gency cases we saw as late as December was incredible electric grid was destroyed, posing a major problem because such a large number of other hospitals have for all Puerto Ricans—and most notably health care, closed. In fact, during the first two weeks, the number education, and emergency services. Hurricane Maria of emergency cases at the hospital tripled. The dedica- had created a humanitarian crisis at a time when tion of our surgeons and all our staff is something to Puerto Rico was the strongest supporter of its fellow be proud about. We would have never in our wildest island nations still reeling from the damage now of dreams thought that in such a short time we would go two storms. from being the rescuers to the rescued. “We are working with the emergency generator right now, and we have been able to get one of the operating rooms (ORs) running for the major trauma Relief efforts continue patients,” said Andrés Guerrero, MD, FACS, chief of On October 17, 2017, a surgical team from Operation surgery at Hospital HIMA San Pablo-Caguas, the day Giving Back of the American College of Surgeons after the hurricane hit. Dr. Guerrero had been taking arrived in Puerto Rico to offer assistance in surgical care of a 58-year-old gentleman who had been transcare. At press time, no visiting surgeons remain on the ferred from St. Thomas during the previous hurricane island, as the assessment determined that the need was two weeks earlier. “He arrived with a small bowel mostly for supplies and infrastructure rather than man- obstruction after receiving an exploratory laparotomy power. Caribbean people are a resilient people and we in his home island and thank God was improving. We will continue to find purpose, gratefulness, and even were in the process of preparing him to go back to St. joy in our most vulnerable time. ♦ Thomas when this happened.” A week after Hurricane Maria, the situation was not much better. The electric grid was down in about 75 percent of the country and eight major hospitals in the island had to close. A number of dialysis units,

FEB 2018 BULLETIN American College of Surgeons OLGA M. JONASSON, MD, LECTURE

• Olga M. Jonasson, MD, Lecture: WELLCOME COLLECTION WELLCOME

22 |

The quiet pioneer who started a revolution: Elizabeth Garrett Anderson • by Kathryn D. Anderson, MD, FACS

V103 No 2 BULLETIN American College of Surgeons OLGA M. JONASSON, MD, LECTURE

HIGHLIGHTS • Summarizes the enduring legacy of Olga M. Jonasson, MD, FACS • Describes the accomplishments of the first woman surgeon in England— Elizabeth Garrett Anderson • Outlines Dr. Anderson’s professional and personal journey

Dr. Jonasson Elizabeth Garrett Anderson

Editor’s note: The following is an edited version of the Olga Meakins, MD, FACS) became ashamed of the dearth M. Jonasson, MD, Lecture that Dr. Anderson delivered at of women in that organization (there were only three Clinical Congress 2017 in San Diego, CA. The presentation of us at that time) and came to Olga for a solution. has been modified to conform with Bulletin style. This was a productive exercise for us and led to many more women being elected to prestigious societies am most grateful to the American College of Sur- and to reaching leadership positions in the College. geons (ACS) Women in Surgery Committee for I was so proud to call her my friend. Iasking me to give this lecture. I am glad to have the chance to honor the surgeon who was a heroine to so many medical students, residents, and surgeons of A tomboy in Victorian England both genders, Olga M. Jonasson, MD, FACS. I am going to speak today of an earlier pioneer for | 23 women in surgery, one with whom I feel a great affinity, although she was born more than a century before Dr. Jonasson’s impact me but whose career had some similarities to my own. Olga had a unique character. She was a great technical I have chosen the first woman surgeon in England, surgeon whose many sayings in the operating room Elizabeth Garrett Anderson, who piqued my interest in her unexpectedly high voice were remembered and several years ago because of our common last name repeated by her former residents, all of whom held and common heritage.* Perhaps it is arrogant to com- her in the highest esteem. She was the first woman pare myself with a woman who certainly overcame in the U.S. to head a major department of surgery, many more obstacles than were placed before me and going from chief of surgery at Cook County Hospital, who pioneered the way for generations of women who Chicago, IL, to chair of the department at Ohio State were determined not to allow the shibboleths of their University, Columbus. She left that post to become day to deter them from their desire to be surgeons. If Medical Director of the ACS Education and Surgical so, I hope that this audience will forgive me. Services Department, as it was then called, a post Elizabeth Garrett was born in June 1836, the year she held for the rest of her career. She ought to have before Victoria became queen of the British Empire. been the first woman President of the College, but She was born in London’s East End, the second child staff members were excluded from consideration for of a pawnbroker who bought and sold goods in this that position. poor section of London. It was undoubtedly expected It was during her tenure at the ACS that I met that a boy would be born, since the Garretts’ first child Olga, when she tasked a number of us to search out was a girl. But Elizabeth never fit the mold of a proper women who should be but were not in leadership English girl in the Victorian era. She was a tomboy. positions in American surgery. This came about when I was also the second child and second girl, and I one of the members of the membership committee know for sure that my father had wished for a boy. of the American Surgical Association (Jonathan L. My biological mother died in childbirth when I was *Thomas I. The World’s First Women Doctors: Elizabeth Blackwell and Eliza- 16 months old and my father lost, besides his wife and beth Garrett Anderson. London, England: Collins Publishers; 2015. our mother, her twin babies who were boys. I have

FEB 2018 BULLETIN American College of Surgeons OLGA M. JONASSON, MD, LECTURE

EXPECTED PATHS IN THE 1800s • BOY GIRL School education Learn sewing and music at home University education Hah! Choose a profession Learn perfect manners Get married, have children but Get married and have children never do housework or child care Spend each day sitting in the drawing room, Spend each day at work or looking after children and home Keep her opinions to herself, unless Share his opinions with others talking about children or home

wondered but never asked my father if he would have with my older sister. But Elizabeth was bored, and encouraged my career in medicine and surgery had her intellect was unused. When she was 22, a group the twins lived. I believe that he would, as he was in of women published a magazine for women, English many ways, like Mr. Garrett, a man before his time. Woman’s Journal. Among these women was one Emily Elizabeth’s father believed wholeheartedly in educat- Davies, who became a dear friend. She invited Eliza- ing all his children to the same extent and Elizabeth beth to hear a lecture given by Elizabeth Blackwell, was sent to a private girls’ school, an unusual event MD, whom some in the audience will recognize as for girls of that time. Boys went to public school (in the first woman physician in the U.S. Dr. Blackwell England, these were inexplicably the private schools), emigrated to the U.S. from England with her family whereas girls were educated at home by a series of and pursued a medical career, culminating in a medi- 24 | governesses. There was a huge difference between cal degree from Geneva Medical College (now Hobart boys’ and girls’ expectations, education, and life expe- and William Smith Colleges) in upstate New York, riences in that era (see sidebar, this page). which was practically impossible in England or the U.S. Mr. Garrett did well in business and moved to a She wanted to be a surgeon but lost an eye to infec- large country home in Aldeburgh, Sussex, as his busi- tion and had to “settle” for a career in medicine. She ness expanded. He made a fortune, so Elizabeth had expected that the women in her audience all wanted the advantage that she never had to scrape and save to be physicians, and she encouraged Elizabeth Gar- for her medical education. I, on the other hand, had rett to pursue her dream. From then on, Elizabeth to win scholarships to go to medical school. How- was determined to get a medical degree and practice ever, Elizabeth’s father did not believe that women medicine and become a surgeon. should be educated after high school or have a career My own introduction to surgery was not at all and at first did not take kindly to her wish to be a traumatic. In my family, there was no revulsion about physician. Her mother never was reconciled to her women being surgeons as there was in Victorian fam- daughter having a career, particularly in surgery, and ilies. I was inspired by a visit to the newly reopened there my experience was similar. For some reason Manchester Art Gallery after World War II; my sister that I never learned, my stepmother was very much and I were taken there by a beloved aunt, a very cul- opposed to my going to a university in the first place, tured woman whose own career as a teacher was never mind medical school. handicapped by the restrictions on women in the era of George V. At the art gallery, I saw a picture simply labeled Introduction to surgery “Theatre” in pencil with a wash of green, by Barbara But I am getting ahead of myself. After Elizabeth left Hepworth, better known in England as a sculptress. I her private school for girls (there were no co-ed schools apparently stood in awe before this drawing for a long then) at the age of 15, she stayed in the family home time. Whether this sealed my career choice, I don’t for nine years, helping to raise her younger siblings know, but I have loved that picture for a very long and developing a deep and lasting friendship with her time. My fantasy life as a young girl always involved older sister that is reminiscent of the relationship I have playacting being a surgeon.

V103 No 2 BULLETIN American College of Surgeons OLGA M. JONASSON, MD, LECTURE U.S. NATIONAL LIBRARY OF MEDICINE

Dr. Blackwell Emily Davies portrait by Dr. Kathryn Anderson (left) as a young Rudolf Lehmann, 1880 girl with her aunt and older sister

Medical education and training all the Cambridge colleges, it was initially only for girls Miss Garrett’s first venture into medicine was to or only for boys, although most now are co-ed. In fact, enter the Middlesex Hospital in London as a nurse. my first room was in the Emily Davies Court. An anec- She could not get into an English medical school, so dote that has little to do with Elizabeth: My rooms in she chose to enter a medical education through the my first and second years were on the ground floor, back door, as a nursing student. I, too, had a delay in a convenient entrance to girls who stayed out after entering medical school, which in Europe, then and curfew and who would be fined if they came through now, was directly after high school, though this was the front door, which was guarded by a diligent ex- | 25 not for the same reason as Elizabeth’s difficulty. I was policeman with a very good memory. A knock on due to take entrance exams (these were advanced, or the window was frequent; the culprit climbed in, said A-level, exams, required for any university entrance) goodnight, and went to her own room. It was rather and hopefully do well enough to win a state scholar- disturbing for one’s sleep, so I was glad to be on the ship to enable me to pay medical school fees. The day first (American second) floor my third year. before the exams were due to start I developed epigas- Back to Elizabeth. At the Middlesex Hospital, she tric pain, which migrated to my right lower quadrant. joined the medical students on their rounds, and after After considerable delay of the whole summer, due a while all pretense of being a nursing student was to our general practitioner’s lack of diagnostic ability, dropped. During this time, she met a physician named my retro-caecal appendix was removed. I missed the John Ford Anderson who was impressed by the young exams, of course, and had to spend an extra year in woman’s depth of knowledge, and they formed a friend- high school before they were available again. This was ship that was to influence her life in the future in a very one of my best years, as I spent the time relearning special way (I will come back to that in a little while). Latin and advanced mathematics, chemistry, physics, For Elizabeth, her troubles began when it was obvi- and biology, as well as taking other fun classes. During ous that she had aspirations to be a physician. The that year, my headmistress encouraged me to apply for all-male student body rebelled at having a woman and take the separate entrance exams for Oxford and rounding with them and threatened to leave. The teach- Cambridge. This is where the requirement for Latin ers were entirely dependent on the students’ fees, and so came in—I doubt it is required any longer. I was suc- they felt they had to dismiss her. Multiple applications cessful at Cambridge and entered Girton College at to medical schools were made without success, and so that university. she took an alternate path and applied for permission What does that have to do with Elizabeth’s career? to audit lectures and take the exam for the license of As it turns out, a lot. Girton College was founded by the Society of Apothecaries, a substitute for the medi- Emily Davies, Elizabeth’s lifelong friend and mentor. cal degree she craved. She attended lectures given by Elizabeth stayed involved with this progressive wom- a member of a very famous family, the Huxleys. T. en’s college, the first resident college for women. Like H. Huxley, the progenitor of this large and brilliant

FEB 2018 BULLETIN American College of Surgeons OLGA M. JONASSON, MD, LECTURE

T. H. Huxley said: “Let us have sweet girl graduates by all means. They will be none the less sweet for a little wisdom; and the golden hair will not curl less gracefully outside the head by reason of there being brains within.” One of Huxley’s descendants taught me physiology at Cambridge.

family, renowned for their research in physiology and writing to this day, said: “Let us have sweet girl graduates by all means. They will be none the less sweet for a little wisdom; and the golden hair will not curl less gracefully outside the head by reason of there being brains within.”† One of Huxley’s descendants taught me physiology at Cambridge. I, on the other hand, never was subjected to prejudice from my fellow medical students, and it was a rare fellow surgical resident who resented my presence. My medical school class in Cambridge had only U.S. NATIONAL LIBRARY OF MEDICINE eight women, but no distinction was made between the men and the women, other than the women did not have to bare their chests in the surface anatomy 26 | class. A few students put out the rumor that the men were doing our dissection for us (as, of course, it was perfect), but that falsehood died a natural death when we were observed. In 1863, Elizabeth was 27 years old, and she again enrolled as a nurse, this time at the London Hospital. She was taken under the tutorship of an orthopaedic surgeon and learned to dissect the human body. Her piecemeal education enabled her to become licensed as an apothecary. My own medical education was also divided. I met my American husband in the dissection room at Cam- bridge and transferred to Harvard University School of Medicine, Boston, MA, after three years, starting with “M.D.”: 1872 wood engraving caricature of Elizabeth the second year there and earning my medical degree Garrett Anderson addressing the London School Board in 1964—a total of six years of medical school. I never took the English final exams. Elizabeth still had ambitions of becoming a surgeon, but in the meantime, she opened a dispensary for the poor in East London, close to the house where she was born. England began to take notice of this determined woman, but many of the comments about her by the British Medical Association (BMA) and The Lancet were scathing and cruel. But Punch, that unusual and often avant-garde magazine, published cartoons of her that †Manton J. Elizabeth Garrett Anderson. New York, NY: E.P. Dutton and Co. Publishers; 1965.

V103 No 2 BULLETIN American College of Surgeons OLGA M. JONASSON, MD, LECTURE U.S. LIBRARY OF CONGRESS PRINTS AND PHOTOGRAPHS DIVISION

Girton College, Cambridge were favorable. Her only patients at first were women A controversial figure and children, but later she had a wide patient base, There were no formal residencies in surgery in the including many men. 19th century, and that was perhaps just as well for Still not satisfied, she continued to apply to medical the time, as Elizabeth was then on her own to do as schools, all of which rejected her. It came to Queen she liked. One of her former tutors at the London Victoria’s ears that this intrepid woman was trying Hospital decided to open a children’s hospital in Lon- | 27 to get a medical degree. The Queen, herself a pio- don’s East End. One of the board members initially neer, having been the first in England to have a child was opposed to her becoming a staff member of this under chloroform anesthesia, became angry after she hospital, but Elizabeth was invited to give a presenta- learned of a supposedly secret visit to Elizabeth by tion to the board. The board member was impressed her eldest and more modern daughter. Victoria was with her presentation and withdrew his opposition. very unsupportive of women for her entire life. There His name was James Skelton Anderson, the brother is a syndrome of minorities, rare but still existing, of John Ford Anderson whom I mentioned earlier. of what I call the “teacher’s pet syndrome”—some- Undoubtedly, Skelton Anderson was influenced by one who believes that as a minority, he or she has his brother’s opinion of Elizabeth. The subsequent no obligation to foster others belonging to the same friendship with Skelton led to their marriage in 1871. minority and often actively opposes them. I guess During her time at the children’s hospital, the now they enjoy being the minority in a field dominated Mrs. Anderson performed surgery in addition to run- by white males. ning medical clinics and a dispensary that she named So, after multiple rejections by the English and after Saint Mary. She often wrote about her nervous- Scottish medical schools, Elizabeth had to go to the ness before a major operation, a feeling I shared with University of Paris, France, for her degree. That her for my entire practice. As education became more institution did not want to admit her, but she drew formalized in England, she served on the London the attention of the Empress Eugenie of France, School Board and was a lively though often contro- who insisted. In fact, at that time, the Empress was versial member. presiding over the French Council of Ministers, When she and Skelton Anderson made it known the deciding body, during the illness of her hus- that they would marry, Elizabeth again experienced band, Napoleon III, and she mandated the entrance prejudice. It was widely believed at that time that of women to medical training at the University of women who married should stay home and become Paris. Elizabeth came first in the final exams out of full-time mothers. So, it was expected that she would a class of eight with a pass rate of three. So, finally, withdraw from practice and that would be a “waste she became a bona fide physician. of her education” and the waste of a place that should

FEB 2018 BULLETIN American College of Surgeons OLGA M. JONASSON, MD, LECTURE U.S. NATIONAL LIBRARY OF MEDICINE

“Miss Garrett before the Board of Medical Examiners at Paris,” wood engraving from Harper’s Weekly, July 23, 1870

have been occupied by a man. I was also questioned during the rest of her career at the hospital. Surgery closely in interviews on a number of occasions with in private houses was not unknown, even in the 20th queries such as: “You are getting married (or you are century, though it involved major operations less 28 | married), and you’ll quit if you have children. Are you and less. In fact, George VI had his pneumonectomy planning to have children?” I always thought this was for carcinoma of the lung in Buckingham Palace. I impertinent and usually replied, sometimes rudely, remember my sister having dental work done under that it was none of the enquirer’s business. anesthesia, given by our general practitioner, which It is not known how Elizabeth responded to such was performed on our kitchen table. I was excluded questions, but she was known to have a sharp tongue from observing this procedure, though I remember and was not afraid to put people in their place, some- that I sneaked in. times to her own disadvantage—just like myself. By the 1870s, the principles and practice of anti- Unlike me, she did go on to have three children: sepsis, promulgated by Lord Joseph Lister, were Louisa, her first-born at the age of 37, another girl, widely used and automatic infection of open wounds who died of meningitis, and Colin, her only boy. Her diminished substantially. Elizabeth stayed at The husband was always supportive, and the marriage New Hospital for Women until she retired. After her lasted until his death from a stroke in 1907. They death, the hospital was renamed the Elizabeth Gar- were two independent people who pursued their own rett Anderson Hospital for Women, and in 1948 it separate interests but were bound together by love was merged into The Royal Free Hospital for Women and affection. when the National Health Service was formed. In 1872, St. Mary’s Dispensary became The New Hospital for Women, largely due to Elizabeth’s efforts. At first, there was reluctance to allow her to Acceptance perform surgery at the hospital. Indeed, she had the The final bastion of male supremacy, the BMA, finally opportunity to perform the first oophorectomy done recognized that it was behind the times, and in 1873 by a woman, but the board would not permit her to do admitted Elizabeth Garrett Anderson as its first and, this onsite. Perhaps they were afraid that they would for 19 years, only female member. A number of papers be blamed if anything went wrong. Undaunted, Eliza- she wrote were published in the British Medical Jour- beth set up a private house with an operating room, nal, though her numerous lectures on diverse subjects and the operation was successful. There was no oppo- were never memorialized. She became in succession sition thereafter, and she performed many operations the president of the New Hospital for Women and

V103 No 2 BULLETIN American College of Surgeons OLGA M. JONASSON, MD, LECTURE WELLCOME COLLECTION WELLCOME U.S. NATIONAL LIBRARY OF MEDICINE

Elizabeth Garrett Anderson The New Hospital for Women, from a magazine of 1899

the Medical School, and Mayor of Aldeburgh. She her colleagues, her mentees, and her community. also became president of the East Anglia branch of She never attained any national honors, though she the BMA. I have shared with Elizabeth the privilege clearly deserved them, because Queen Victoria never of being the first woman to be given several honors, forgave her for stepping out of the mold of the Vic- | 29 my own within the pediatric surgical community torian lady and, horrors, getting a medical degree and in this College, my medical home. from France. Her son, Edward VII, did not rectify Elizabeth was instrumental in gaining the admis- his mother’s omission. Ultimately, Elizabeth became sion of women to the Royal College of Physicians, forgetful and developed progressive dementia, a fate which reminds me of the efforts of my colleagues (all I hope to avoid. She died in 1917, at the age of 81. MD, FACS) ACS Past-President Patricia J. Numann (who at Clinical Congress 2017 was presented as an Icon in Surgery); Patricia K. Donahoe; and ACS Clearing the path for other women Foundation Chair Mary H. McGrath, among many I have stressed the early struggles of this great pioneer others over the years, after we were formed into a of women. Once she had obtained medical training, her group by Dr. Jonasson with the objective of identi- social position and her wealth allowed her to do many fying “worthy women.” But Elizabeth, like me, was things that a poor woman could not accomplish. For strenuously opposed to quotas. I have always felt that all her life, she helped those women coming after her if I was refused to attain a position I was qualified and, along with her friendship with Emily Pankhurst, for, it demeaned the position, but if I was appointed the famous suffragette, helped to obtain the vote for only because I was a woman, it demeaned me. I never women and better their position in society, regardless enjoyed being the token woman any more than Eliza- of whether they were physicians. She certainly paved beth did. the way for us all, always striving to reach equality but Mrs. Anderson, as she would have been known in not receive special privileges. England, a title without the appellation “doctor” that I will close with Elizabeth’s words: “I ask you to to English surgeons is an honor (stemming from the turn your thoughts to the future and to consider time of the barber-surgeons), lived for 16 years after where further progress is most wanted.”† We must her retirement at the age of 65 in 1901. She spent the guarantee that future patients will receive not only rest of her life surrounded by family and beloved of the latest in technological advances but the best in †Manton J. Elizabeth Garrett Anderson. New York, NY: E.P. Dutton and humanitarian care that transcends gender, ethnicity, Co. Publishers; 1965. religion, and specialty. ♦

FEB 2018 BULLETIN American College of Surgeons PRECISION SURGICAL ONCOLOGY

Precision surgical oncology?

The treasure is in the tissue

30 | by Carolyn C. Compton, MD, PhD, FCAP, and Bruce J. Averbook, MD, FACS

n the era of precision oncology, the molecular biological data HIGHLIGHTS derived from patient biospecimens directly influences patient • Summarizes the challenges Imanagement. For cancer resection specimens, traditional of obtaining uncompromised types of specimen-derived data, such as tumor type, grade, path- cancer resection specimens ological stage, and resection margin status, also are essential and must be accurately reported; however, these data are derived • Describes cold ischemia time and its effect on molecular analysis data from histopathological observation and are rarely significantly compromised by preanalytical variables in the biospecimen “life • Outlines ACS and ASCO-CAP cycle” (see Figure 1, page 31). Therefore, little, if any, attention collaborative efforts to improve needed to be directed toward the standardization, control, and the integrity of biospecimens tracking of preanalytical variables. With molecular assessment now standard for many cancers and increasingly required for many others, the bar for the molecular quality of cancer biospecimens has gone up and has given preanalytics a much greater level of significance. Preanalytical variables, for any patient biospecimen, include all of the processing, handling, and transport procedures the specimen undergoes, along with all of the physical and environmental factors to which it is exposed before being analyzed. Many of these variables have profound effects on the molecular quality of patient biospecimens but may have little or no effect on morphological parameters. Thus, historically, before molecular testing of patient

V103 No 2 BULLETIN American College of Surgeons PRECISION SURGICAL ONCOLOGY

FIGURE 1. THE LIFE CYCLE OF A SURGICAL RESECTION SPECIMEN

Medical/ Restocking Handling/ Scientific Patient surgical Acquisition Storage Distribution unused processing analysis procedures sample

The specimen is biologically viable

Pre-acquisition Post-acquisition

specimens became standard practice, the bar for pre- halts further biological activity or molecular degrada- analytical variation was only as high as it needed to be tion and represents a critical and time-sensitive step in for routine histopathology. tissue processing. Despite the fact that the current level of atten- Cold ischemia time affects different classes of bio- tion to and control over preanalytical variables is molecules in different ways, depending on the relative wholly inadequate for molecular testing, it has never lability or stability of the molecular entity. However, been changed appropriately to ensure the molecular cold ischemia time should always be as short as possible, integrity of patient specimens to meet the needs of but a maximum of one hour would be a reasonable goal precision oncology. Because professional perceptions that is both data-driven and practicable in the clinical about biospecimen stewardship, for both surgeons and setting.* | 31 pathologists, are still based largely on this historically At present, the only enforced cold ischemia time in low bar for biospecimen quality, there is an urgent need pathology practice comes from the American Society to change the culture of surgery and surgical pathol- of Clinical Oncology/College of American Pathologists ogy practice to ensure the control of specimen quality (ASCO-CAP) human epidermal growth factor recep- is a primary focus. Safeguarding the molecular quality tor 2 (HER2) testing in breast cancer guidelines with of patient biospecimens is vital for precision oncology a strong recommendation of time to fixative within and must be regarded as an integral part of the profes- one hour.* With the exception of this special case, cold sional responsibilities of surgeons and pathologists. ischemia times for cancer resection specimens can vary significantly—from minutes to days—and there are no requirements to record, let alone control, cold ischemia Cold ischemia time times for these specimens. Thus, the molecular qual- One of the most important preanalytical variables starts ity of the vast majority of cancer resection specimens, in the operating room (OR) and is known as cold isch- and, therefore, their “fitness” for molecular testing, is emia time—the period that elapses between removal of largely or completely unknown at the time of analysis. the tissue from the body by the surgeon and the fixing When the molecular composition is altered and the or freezing of the tissue (processes known as tissue quality of tissues is compromised, as often occurs as a stabilization) by the pathologist. During this time, result of cold ischemia-related factors, the molecular the tissue is still viable and experiences major biologi- analysis data derived from the tissue is unreliable. In cal stress in the form of anoxia, nutrient deprivation, fact, the quality of the molecular data derived from a temperature change, and desiccation with subsequent biospecimen can never be higher than the quality of changes in gene expression, protein translation and the molecular analytes in that specimen. modification, and molecular degradation. Stabilization The ultimate risk, of course, is that incorrect molecular analysis data generated from compromised tissue *Wolff AC, Hammond ME, Hicks DG, et al. Recommendations for hu- specimens will lead directly or indirectly to inappro- man epidermal growth factor receptor 2 testing in breast cancer: Amer- ican Society of Clinical Oncology/College of American Pathologists priate or erroneous patient management decisions, or Clinical Practice Guideline Update. J Clin Oncol. 2013;31(31):3997-4013. worse, fatal errors in judgment. In a setting in which

FEB 2018 BULLETIN American College of Surgeons PRECISION SURGICAL ONCOLOGY

the results of a companion diagnostic test are the gate- time that elapses prior to gross examination and tissue way to the informed use of a specific (often costly) stabilization. The challenge of controlling and record- therapy, the stakes are high, and neither a false nega- ing cold ischemia time can only be met if surgeons tive nor a false positive can be tolerated. and pathologists alike change these practices and jointly share the responsibility for custodianship of the specimen. The quality gap The case for extending control over cold ischemia time for every surgical resection specimen from Joint dialogue every cancer patient would seem to be evident given Pathologists are stepping forward to address their part the potential detrimental impact of this variable of the preanalytics challenge, but much remains to on molecular integrity and the increasing focus on be done, both inside and outside of the discipline of specimen-derived molecular data. Nevertheless, most pathology. Although the ultimate goal is a sweeping 32 | cancer resection specimens fall into a quality gap in the improvement in the molecular integrity of all resec- chain of custody from surgeon to pathologist, largely tion specimens for all cancer patients, this milestone due to the aforementioned problem in professional cannot be achieved without the collaborative efforts perception and practice. of surgeons. Specifically, the issue has to do with a surgeon’s perception that safe and effective excision of the dis- eased tissue is his or her primary responsibility while Initiating a culture change the custodianship of the resected tissue is not part of The ASCO-CAP and the American College Surgeons, this duty. Surgeons typically delegate custodianship under the auspices of the Commission on Cancer (CoC), to OR staff and other hospital staff who may handle/ have initiated a joint dialogue emphasizing the impor- carry the specimen, place it in a holding station (often a tance of surgeons and pathologists working together to refrigerator), or deliver it to the pathology department. improve the molecular integrity of resection specimens. No records are required to document the variations in The CoC has appointed Bruce Averbook, MD, FACS, physical conditions to which specimens are subjected a coauthor of this article, as its representative to this nor is the time lapse between resection and delivery effort with the goal of defining coordinated surgical to pathology recorded. and pathology practices that ensure coordinated cus- Pathologists, for their part, typically consider the todianship for surgical resection specimens in routine specimen to enter their domain of professional respon- practice. The CoC and the ASCO-CAP agree that clo- sibility only after it is delivered to their department. sure of the quality gap for surgical resection specimens Their knowledge of the events preceding the delivery is essential for high-quality care of cancer patients and of the specimen to the pathology department, includ- that this effort is the joint responsibility of surgeons ing the exact time of resection and removal of the and pathologists. specimen (the start of cold ischemia time), is usually Changing the cultures of both the OR and surgi- minimal to nonexistent. However, it is important to cal pathology practice is a daunting challenge. Not note that even after the specimen has been accessioned only will it require educational initiatives for surgeons to pathology, there is no requirement to control or and surgical pathologists, but for other essential staff record the duration or conditions of the cold ischemia such as nurses, radiology staff (for example, for breast

V103 No 2 BULLETIN American College of Surgeons PRECISION SURGICAL ONCOLOGY

Changing the cultures of both the OR and surgical pathology practice is a daunting challenge. Not only will it require educational initiatives for surgeons and surgical pathologists, but for other essential staff such as nurses, radiology staff...and pathology assistants as well.

tissue undergoing specimen imaging), and pathology of personnel for transporting specimens as soon as they assistants as well. The time during which the resec- are ready for delivery or the existence of long distances tion specimen sits at room temperature after removal, between the OR and the pathology department. In addi- the length of time required for packaging, labeling, tion, the lack of availability of pathologists at satellite and transport, and the number of handoffs between outpatient surgery centers may need to be addressed at carriers/transporters all become important consid- some institutions. Lastly, the transplant patient presents erations for systems analysis at any institution. The another urgent circumstance that will require more surgeon will need to be aware of, and seek to remedy, flexibility on the part of the pathology team to be avail- these issues at his or her institution, which will vary able as required. significantly depending on practice setting. It will be essential to always track and record the time from tissue resection/harvest to the tissue stabili- A step forward zation step and to foster good communication between Closure of the quality gap for cancer resection speci- the OR and the pathology team. In institutions with mens is an essential step forward for quality practice | 33 high volumes of cancer surgery, it may even be neces- of precision oncology, but it will also have widespread sary to have dedicated personnel who serve as “tissue effects on translational research. Most of the biospeci- navigators” and have specimen handling, transport, mens that are used in correlative scientific studies of and annotation (recording of key preanalytical factors) patients in clinical trials and that contribute directly as their primary role. Alternatively, this role might be or indirectly to biomarker and/or new product devel- developed as a specialty focus for existing staff, such opment come from clinically derived samples. Thus, as pathology assistants. improving the molecular quality and consistency Routine logistical and operational issues will of cancer resection specimens will simultaneously need to be addressed on an institution-specific basis improve the quality of patient care and translational to accomplish the goal of controlling cold ischemia research with obvious benefits for cancer patients, time. Special or unusual circumstances that could affect both present and future. cold ischemia time may need to be addressed as well. Though challenging, closing this quality gap falls For example, it may no longer be acceptable to keep clearly into the category of “the right thing to do.” resected cancer specimens in a holding refrigerator CoC accreditation standards may change in the future overnight and deliver them to the pathologist in the with regard to documentation of cold ischemia time, morning for processing. This revised process would timely specimen management, and compliance with include surgical specimens resected after usual business a goal of tissue stabilization within an hour. We need hours, such as add-on cases or emergency cancer cases to start now. ♦ (for example, bowel obstruction or perforation). Wire localization procedures or any localization step that requires radiological confirmation by tissue re-imaging after harvest/resection can increase cold ischemia time both in time for imaging and time for transport from the OR to radiology and back and then on to pathology. A variety of other challenges also may impede prompt specimen processing, including the availability

FEB 2018 BULLETIN American College of Surgeons HISTORY OF THE SCALPEL

TheThe historyhistory ofof thethe scalpel:scalpel: FromFrom flintflint toto zirconium-coatedzirconium-coated steelsteel

34 |

byby JasonJason B.B. Brill,Brill, MD;MD; EvanEvan K.K. Harrison,Harrison, MD;MD; MichaelMichael J.J. Sise,Sise, MD,MD, FACS;FACS; andand RomeoRomeo C.C. Ignacio,Ignacio, Jr.,Jr., MD,MD, FACSFACS

V103 No 2 BULLETIN American College of Surgeons HISTORY OF THE SCALPEL

HIGHLIGHTS • Describes the origins and evolution of the scalpel • Summarizes the transition to the modern scalpel • Outlines key developments such as retractable blades and their effect on the surgical profession

Editor’s note: The following article is based on a poster presented at the History of Surgery Poster Session at the American College of Surgeons (ACS) Clinical Congress 2017 FIGURE 1. in San Diego, CA. The session is sponsored each year by FLINT DAGGER OF ÖTZI THE ICE MAN the Surgical History Group. For more information, go to facs.org/archives.

he surgical knife, one of the earliest surgical instruments, has evolved over 10 millennia. TWhile the word “scalpel” derives from the Latin word scallpellus, the physical instruments surgeons use today started out as flint and obsidian cutting implements during the Stone Age. As surgery developed into a profession, knives dedicated to specific uses also evolved. Barber-surgeons embel- lished their scalpels as part of the art of their craft. Image © South Tyrol Museum of Archaeology/ | 35 Later, surgeons prized speed and sharpness. Today’s Harald Wisthaler, Bolzano, Italy advances in scalpel technology include additional safety measures and gemstone and polymer coat- ings. The quintessential instrument of surgeons, the scalpel is the longstanding symbol of the dis- FIGURE 2. cipline. Tracing the history of this tool reflects the EXAMPLE OF A ROMAN SCALLPELLUS evolution of surgery as a culture and as a profession. AND SIMILAR INSTRUMENTS

Origins Pinpointing a specific period of time when a cutting implement became the first surgical knife depends largely on perspective. Shells, razor-like leaves, bamboo shoots, and even fingernails may all be viewed as early surgical instruments. Thumbnails for newborn circumcisions, scarification via plant stems, and venesection with sharks’ teeth served as the first examples of sharp tools for procedures on the human body.1,2 John Kirkup, MB, BS—a retired surgeon and hon- Courtesy of Historical Collections & Services, Claude Moore orary curator of the Historical Instruments Collection Health Sciences Library, University of Virginia, Charlottesville at the Royal College of Surgeons of England— researched the history of surgical tools for more than 20 years.3 According to Dr. Kirkup, circumcision with sharpened stones, one of the earliest recorded elective procedures, evolved into knives used for basic procedures.4 Excavations of archaeological sites dating to

FEB 2018 BULLETIN American College of Surgeons HISTORY OF THE SCALPEL

FIGURE 3. FIGURE 4. SURGICAL SET FROM THE DETACHABLE BLADES FROM CIRCA 1900 AMERICAN REVOLUTIONARY WAR

Courtesy of the Royal College of Physicians Displayed in the Smithsonian and Surgeons of Glasgow, Scotland National Museum of American History, the set includes wood and iron handles and required routine sharpening of the blades

the Paleolithic and Neolithic periods revealed knives blade with a single edge and sharp point, containing for surgical use as early as 10,000–8,000 BC.5 the same essential features of the modern scalpel as Blades were initially composed of flint, jade, defined by Stedman’s Medical Dictionary: “A pointed 36 | and obsidian, with specific pieces chosen for their knife with a convex edge.”10,11 In Rome, Galen and sharp edges. Fracture and flake techniques were Celsus used an instrument with this shape—a small, then employed to refine these early blades into cut- sharp blade for specialized used for incision and drain- ting instruments with desired characteristics, making age, tendon repairs, and vivisections (see Figure 2, these objects among the first human-refined tools.6 page 35). A particularly well-preserved prehistoric blade The Romans named their version of this tool the mounted onto a handle was found in 1991, preserved scallpellus, the diminutive form of the word scalper in ice near the Austrian-Italian border (see Figure 1, (“incisor” or “cutter”).12 With the collapse of the page 35). These types of tools were used for scarifica- Roman Empire, surgical innovation flourished in the tion, venesection, lancing, and circumcision. In fact, Islamic Golden Age. Albucasis (Abū al-Qāsim Khalaf these instruments were still used for many of the same ibn al-‘Abbās al-Zahrāwī, 936–1013) in the Caliphate purposes by Alaska Native tribes well into the 19th of Córdoba (modern Spain) used a scalpel that held century.7 Evidence of obsidian blades used for more a retractable blade.13,14 Surgical instruments became complex procedures such as craniotomies appeared even more varied and specialized with the Renaissance around 4000 BC in prehistoric Anatolia, modern-day in the 14th and 15th centuries. Embellishments to the Turkey. Some archeological specimens are still sharp scalpel included fixed and folding blades and special- enough to incise skin.8 ized tips, such as lancets, bistouries, and double-edged blades called catlins. Barbers working during the Renaissance period, Transition to modern scalpels including fathers of modern surgery such as Guy Metal blades replaced sharpened stone: first it was de Chauliac and Ambroise Paré, used ornamented copper (3500 BC), followed by bronze and then iron scalpels with artistic flourishes that enjoyed wide (1400 BC). But it wasn’t until 400 BC that the concept popularity for several hundred years.15 The require- of a surgical knife was first described by Hippocrates.9 ments of antisepsis and asepsis in the late 19th century He used the term “macairion,” a smaller version of a subjected instruments to caustic chemicals and pres- Lacedaemonian sword called a “machaira,” to describe surized steam sterilization, so nonmetallic decorations the surgical tool. The machaira was a broad-cutting became obsolete (see Figures 3 and 4, this page).

V103 No 2 BULLETIN American College of Surgeons HISTORY OF THE SCALPEL

Disposable scalpels King C. Gillette founded the American Safety Razor FIGURE 5. Company (later the Gillette Safety Razor Company) in 1901 to produce and market a handle-and-frame MORGAN PARKER’S ORIGINAL PATENT device that held disposable razors. John Murphy, MD, FACS, a Chicago, IL, surgeon and one of the founders of the ACS, adapted Gillette’s razors into a tool that could be used when performing surgical operations. Dr. Murphy’s version featured interchangeable blades, although it required extra instruments to complete a blade exchange.16 In 1914, Morgan Parker, a 22-year-old engineer, invented the two-piece blade-and-handle medical scalpel that is used in ORs today.10 It allowed rapid mass- produced, sharp blades to be used and exchanged on standard reusable handles. According to legend, Mr. Parker’s uncle, a New York, NY, surgeon, became impa- | 37 tient with the cumbersome process of the blade exchange in his busy practice. A glance at Mr. Parker’s elegant solution reveals its genius (see Figure 5, this page). He stated the following in his original patent application: “For the purpose of securing the blade to the handle, headed studs are preferably provided on the handle adapted to co-act with suitable slots in the blade. When such headed studs and slot are employed, the blade may be readily secured upon the handle and when in position will be held so rigidly as to preclude the possibility of movement relative to the handle.”17 When Mr. Parker presented his scalpel at the ACS Clinical Congress of 1915 in Boston, MA, its reception encouraged him to take it to production. Mr. Parker, an engineer but not a businessman, sought a partner. The first name listed alphabetically in the phone book Source: United States Patent and under “medical suppliers” was C.R. Bard. Together, they Trademark Office, www.uspto.gov formed the Bard-Parker Company, which became one of the iconic names in surgery. They developed cold sterilization to avoid superheating, which killed micro- organisms, but also dulled the blade. The rib-back handle replaced those that bore the paired studs in 1936 in order to ensure one-way fitment between the blade and handle. The numbering system of blades and handles is arbitrary, a fact that likely confirms the suspicions of generations of surgical interns. As part of the Bard-Parker

FEB 2018 BULLETIN American College of Surgeons HISTORY OF THE SCALPEL

marketing scheme, each new blade and handle REFERENCES design was given a new number and occasionally 1. Scultetus J. The Chyrurgeon’s Storehouse. London, UK: Starker; a letter that denoted a “new and improved” model 1674. 18 (for example, #15C). As a result, a given number 2. Pankhurst R. An historical examination of traditional Ethiopian has no relation to size, shape, sharpness, or even medicine and surgery. Ethiop Med J. 1964;3:157-167. a place in the product timeline. 3. Kirkup J. The history and evolution of surgical instruments VI: The surgical blade: From finger nail to ultrasound. Ann R Coll Surg Engl. 1995;77(5):380-388. 4. Jacobs MS. Circumcision. Ann Med Hist. 1939;1(3):68-73. Modern additions 5. Rezaian J, Forouzanfar F. Consideration on trephinated skull In the modern era, hardened alloys, such as 316L in the Ŝahre-e Sukte (Burnt City) in Sistan. Res Hist Med. and 440C stainless steel, replaced carbon steel in 2012;1(4):157-168. most settings. Stainless steel had superior corro- 6. Moser L, Pedroti A. The Neolithic settlement of Lugo di Grezzana (Verona): Preliminary report. In: Belluzzo G, Salzani sion resistance, and reusable handles benefited L, eds. From Earth to Museum: Exhibition of Prehistoric and most from the high chromium content of stain- Protostorical Finds of the Last Ten Years of Research From the Veronese less steel. Retracting blades, a concept dating to Territory. Legnago, Italy: Fondazione Foroni; 1996. the time of Albucasis of the 10th century, became 7. Ackerknecht EH. Primitive surgery. Am Anthropol. 38 | an increasingly common safety feature. Nickel 2009;49(1):25-45. 8. Shadbolt P. How Stone Age blades are still cutting it in modern and chromium plating became less common. surgery. CNN. Available at: www.cnn.com/2015/04/02/health/ Recent technological improvements include surgery-scalpels-obsidian/index.html. Accessed November 10, zirconium nitride, diamond, and polymer coat- 2017. ing that enhance the cutting edge. For all the 9. Adams F. The Genuine Works of Hippocrates, Vol. II. London, UK: improvements evident in contemporary surgical Sydenham Society; 1849. 10. Ochsner J. The surgical knife. Bull Am Coll Surg 1999;84(2):27-37. technology, electron microscopic images actu- 11. Stedman TL. Stedman’s Medical Dictionary for the Health ally confirm that the edge of Neolithic obsidian Professions and Nursing. Philadelphia, PA: Lippincott Williams & blades exceed today’s steel scalpels in sharpness.19 Wilkins; 2005. 12. Bliquez L. Tools of the empire. In: The Tools of Asclepius: Surgical Instruments in Greek and Roman Times. Boston, MA: Brill; 2015. 13. Elgohary MA. Al Zahrawi: The father of modern surgery. Ann Conclusion Ped Surg. 2006;2(2):82-87. The scalpel, since its first use as a medical knife by 14. Ahmadi SA, Zargaran A, Mehdizadeh A, Mortazavi SMJ. the Romans, has been a symbol of the surgeon. Remanufacturing and evaluation of Al Zahrawi’s surgical Its evolution in many ways mirrors the prog- instruments, Al Mokhdea as scalpel handle. Galen Medical Journal ress of those wielding it. Prehistoric humans [online]. 2013;2(1):22-25. Available at: www.gmj.ir/index.php/ gmj/article/viewFile/42/27. Accessed December 19, 2017. used stone tools occasionally for medical uses. 15. Rutkow IM. On scalpels and bistouries. Arch Surg. 2000;135(3):360. The Greeks and Romans advanced both knowl- 16. Ochsner J. Surgical knife. Tex Heart Inst J. 2009;36(5):441-443. edge and skill while creating dedicated surgical 17. Parker M. Detachable-blade knife. U.S. Patent US 1139796A. knives. The barber-surgeons refined techniques Available at: http://pdfpiw.uspto.gov/.piw?Docid=01139796. as they refined the instruments used for them. Accessed December 19, 2017. 18. Arrow AK. Solving the mystery of the scalpel blades: What do Asepsis mandated sweeping changes in both the numbers mean? Plast Reconstr Surg. 1996;97(4):861-862. scalpel and surgical practice. Today, the modern 19. Buck BA. Ancient technology in contemporary surgery. West J surgeon relies on a wide array of technologi- Med. 1982;136(3):265-269. cally advanced and ever-changing equipment, yet the operation still begins with the scalpel, the profession’s oldest instrument. ♦

V103 No 2 BULLETIN American College of Surgeons 2017 FEDERAL LEGISLATIVE GAINS

ACS manages 2017 legislative gains despite Hill focus on

ACA repeal, tax reform | 39 by Kristin McDonald

ongress concluded 2017 with a landmark vote priorities, both in the debate over the ACA, as well as on a tax package that contained a repeal of the with respect to issues that affect surgeons and surgi- Cindividual health insurance coverage mandate cal patients. in the Affordable Care Act (ACA) in 2019. This action The College’s policy priorities are set and exam- represents the most the Republicans could agree to ined annually at the Division of Advocacy and Health in their efforts to repeal and replace the ACA—after Policy’s (DAHP’s) meeting with the Health Policy years of health care debate marked by the divisive and Advocacy Group (HPAG) at the beginning of the politics that accompanied any discussions surround- year. The issues facing the practice of medicine are ing “Obamacare.” And while repeal of the individual numerous and broad in scope. As such, the DAHP mandate does undo a key component of the ACA, it and HPAG had 44 policy priorities to discuss with is likely that additional efforts to repeal, adjust, or state and federal decision makers at the beginning of improve other portions of the ACA will occur in 2018. 2017; that list only grew over the course of the year as The repeal of the individual mandate will prob- Congress delved deeper into various aspects of health ably continue to drive the health care conversation in care. While not all 44 issues received attention from 2018. However, providers and their patients are facing Congress in 2017, they are topics on which the DAHP many issues beyond the ACA, and in an environment continued to educate members of Congress, as well as that is mostly overcast with such a large-scale priority, to advocate and develop solutions over the course of it can leave little daylight for other legislative issues. 2017. It is likely that 2018 will see a similarly lengthy It is in this context that the American College of Sur- list, and the College will continue to push for appro- geons (ACS) continues to fight for the College’s policy priate action on each issue.

FEB 2018 BULLETIN American College of Surgeons 2017 FEDERAL LEGISLATIVE GAINS

The College has taken the lead on a number of competing priorities but have expressed openness to legislative activities, including efforts to improve the addressing concerns related to MIPS this year. Ensur- implementation of the Medicare Access and CHIP ing that surgeons can succeed in MIPS remains a top (Children’s Health Insurance Program) Reauthoriza- priority for the College in 2018. tion Act of 2015 (MACRA); ensure access to surgeons in shortage areas; provide appropriate pain control; provide Stop the Bleed® training to members of Con- Workforce shortages gress; and advocate for high-quality cancer care. As For a number of years, the College has been raising the College has worked to develop solutions on legis- awareness about the growing shortages in the surgi- lative priorities, it also has sought new ways to engage cal workforce. A 2016 study prepared by the University Fellows as grassroots activists through in-district of North Carolina at Chapel Hill found that while the meetings, virtual Hill days, and improvements to supply of general surgeons will grow slightly by 2030, SurgeonsVoice—the ACS Professional Association’s it will not match overall growth in the U.S. population 40 | nationwide, interactive advocacy program—to make or the demand for surgical services. taking action on legislation easier for busy surgeons. A 2017 report from the American Association of A summary of the College’s key activities in 2017 Medical Colleges projects shortages in all surgical spe- follows. cialties by 2030. Additionally, the Health Resources and Services Administration (HRSA) estimates the supply of general surgeons will not keep pace with popula- MACRA tion growth, falling behind by nearly 3,000 general The College has been closely tracking the implementa- surgeons by 2025. HRSA also highlights that no con- tion of MACRA, including moving the ACS-Brandeis sistent national or regional data source is available to Advanced Alternative Payment Model through the estimate baseline shortages or surpluses and points approval process at the U.S. Department of Health and out that the lack of data forces the agency to use the Human Services (HHS). Frank G. Opelka, MD, FACS, current (2013) supply of general surgeons as the base- ACS Medical Director, Quality and Health Policy, in line for demand. November 2017, testified on this process before the U.S. Reps. Larry Bucshon, MD, FACS (R-IN), and U.S. House Committee on Energy and Commerce Ami Bera, MD (D-CA), and Sens. Charles Grassley Health Subcommittee’s hearing, MACRA and Alter- (R-IA) and Brian Schatz (D-HI), introduced the Ensur- native Payment Models: Developing Options for ing Access to General Surgery Act of 2017 (H.R. 2906/S. Value-based Care. 1351) legislation that would direct the government to The ACS also is carefully monitoring implemen- study what constitutes a general surgery shortage area, tation of the Merit-based Incentive Payment System determine where such shortages exist, and whether a (MIPS) and offering solutions to problems with the formal general surgery shortage area designation is program. While most improvements to MIPS will be warranted. The bill also grants authority to the HHS done through the regulatory process, some changes Secretary to make a formal designation based on the only Congress can make. The key congressional data. committees with jurisdiction over MACRA, such The legislation has been a key component of the as the Senate Finance Committee, were unable to College’s grassroots efforts. It was a topic during the focus attention on improvements in 2017 because of 2017 Advocacy Summit in Washington, DC, with

V103 No 2 BULLETIN American College of Surgeons 2017 FEDERAL LEGISLATIVE GAINS

more than 300 surgeons participating in more than to their members of Congress during the August in- 200 meetings on Capitol Hill to raise awareness of district work period. the shortage. Fellows also have sent nearly 500 letters Furthermore, in October 2017, the College hosted to Capitol Hill encouraging members of Congress to a Stop the Bleed training program on Capitol Hill for support the legislation. members of Congress and their key staffs. The congressional event focused on how early intervention from a Stop the Bleed-trained individual can save the Opioids life of someone suffering from a bleeding injury. In Congress continues to seek ways to address the grow- addition to providing valuable training to lawmak- ing opioid crisis. Recently, the College was asked to ers, this event showcased the vital role that surgeons join the congressional Bipartisan Working Group, a play in educating the public. coalition of legislators from both sides of the political ACS Fellows who led the training include ACS spectrum who meet regularly to discuss pending issues Regent Lenworth M. Jacobs, Jr., MD, MPH, FACS; before Congress, to share the physician perspective on Leonard J. Weireter, Jr., MD, FACS; Mark L. Gestring, | 41 solutions to the opioid epidemic. John Daly, MD, FACS, MD, FACS; John H. Armstrong, MD, FACS; Joseph Co-Chair of the ACS Patient Education Committee, V. Sakran, MD, MPH, MPA, FACS; and Jack Sava, participated in the meeting and used his experience as MD, FACS. Congressional special guests included co-chair to provide key insights to lawmakers regard- Dr. Bera and Reps. Phil Roe, MD (R-TN); Raul Ruiz, ing how to best address the opioid crisis, while also MD (D-CA); and Brad Wenstrup, DPM (R-OH), who ensuring that physicians can provide appropriate care provided opening remarks. to their patients. Members of Congress and their staff left the pro- Following the working group meeting, Dr. Daly gram with a better understanding of how to become met with other lawmakers to highlight several of the lifesaving immediate responders, and of the value of informational tools the ACS is using to educate both Stop the Bleed training. They also left with the inten- patients and prescribers about the effects of opioids. tion of encouraging their colleagues to participate in These materials include the Statement on the Opioid the program. As a result, the DAHP developed several Abuse Epidemic (facs.org/about-acs/statements/100- Stop the Bleed initiatives on Capitol Hill that will be opioid-abuse), a patient education guide, and the August a part of 2018 programming. opioid-focused edition of the Bulletin (bulletin.facs. org/2017/08). Through these congressional meetings, the ACS continues to play an active role in addressing Cancer the opioid epidemic, an issue likely to receive contin- ACS Cancer Programs, including the Commission ued policymaker attention in 2018 and beyond. on Cancer (CoC) and the National Accreditation Program for Breast Centers, are consortiums of professional organizations dedicated to improv- Stop the Bleed ing survival and quality of life for cancer patients The Stop the Bleed® program has captured the atten- through standard-setting, prevention, research, edu- tion of key members of Congress. In 2017, as part of cation, and accreditation. DAHP staff worked with a renewed focus on in-district meetings, the DAHP the CoC’s Advocacy Committee to develop a robust assisted Fellows in providing bleeding control training advocacy agenda that includes issues ranging from

FEB 2018 BULLETIN American College of Surgeons 2017 FEDERAL LEGISLATIVE GAINS

palliative care, to cancer research funding, to a spe- ACS members can actively influence key surgi- cial resolution championed by Reps. Lynn Jenkins cal issues throughout 2018. The following are some (R-KS) and Mike Thompson (D-CA) that recognizes examples of ways to be engaged: the importance of voluntary accreditation by ACS Cancer Programs to ensure access to high-quality • Stay informed about ACS legislative priorities by read- cancer care. ing ACS NewsScope weekly, checking the ACS Advocacy This portfolio of issues was part of the College’s web page at facs.org/advocacy and surgeonsvoice.org, and first virtual Hill day, an event that enabled surgeon reading “Dateline: DC” in the online Bulletin. advocates across the nation to participate and make their voices heard by colleagues, members of Con- • Build relationships with your lawmakers and their local gress, and the public via social media. Participants staff by arranging in-district meetings, attending town used Twitter hashtag #cancerprogramsday and other halls, or inviting them to visit your surgical practice; ACS handles to advocate for policies that could affect details for setting up an in-district meeting are avail- 42 | the future of cancer care; contacted members of Con- able at facs.org/advocacy/participate/surgeonsvoice/guide. gress via SurgeonsVoice; and shared information via social media about how cancer education, research, • Respond to ACS calls to action by contacting your and prevention saves lives. lawmakers through SurgeonsVoice at surgeonsvoice.org. The ACS Cancer Programs October 2017 virtual Capitol Hill day resulted in 60 letters to members • Mark your calendar to participate in the 2018 Leader- of Congress; more than 245 #cancerprogramsday ship & Advocacy Summit, May 19–22 in Washington, tweets; more than 14,340 Twitter impressions (inter- DC, as well as your local ACS chapter’s state lobby day. actions or replies from others online), including 50 retweets; and engagement of several members of Con- • Learn about the ACSPA-SurgeonsPAC at surgeonspac.org. ♦ gress, including Representative Thompson and Sen. Lisa Murkowski (R-AK).

More ways to get involved These bills and examples of engagement represent only a small snapshot of the efforts of the College to advocate on behalf of the Fellows, but they do highlight the diverse set of policy priorities the ACS seeks to advance each year. While the politics in an election year are likely to be even more heated than in 2017, the all-consuming debate over the repeal and replacement of the ACA should consume less time, allowing for more movement on some of the key issues facing medicine. The College will continue to raise awareness in 2018 and encourage the resolution of key issues facing surgeons and surgical patients.

V103 No 2 BULLETIN American College of Surgeons STATEMENT

Statement on Cannabis Regulation and Risk of Injury

The American College of Surgeons (ACS) Committee on Trauma (COT), through its Subcommittee on Injury Prevention and Control, developed the following Statement on Cannabis Regulation and Risk of Injury to educate surgeons and other medical professionals on the significance of cannabis and its effect on safety and the risk of injury. The ACS Board of Regents approved the statement at its October 2017 meeting in San Diego, CA.

REFERENCES

1. Center for Behavioral Health Statistics and Quality The ACS recognizes the following: (2016). Key Substance Use and Mental Health Indicators in the United States: Results from the 2015 National Survey on • Cannabis is among the most commonly abused sub- Drug Use and Health (HHS Publication No. SMA 16-4984, stances in the U.S., and its use has increased over the NSDUH Series H.51). Available at: www.samhsa.gov/ past decade, while active components have increased data/sites/default/files/NSDUH-FFR1-2015/NSDUH- | 43 FFR1-2015/NSDUH-FFR1-2015.pdf. Accessed January 17, almost sixfold in content and potency over the last three 2018. decades. Cannabis is also one of the most commonly 2. ElSohly MA, Ross SA, Mehmedic Z, Arafat R, Banaham detected intoxicants in driving-related incidents.1-4 BF 3rd. Potency trends of delta-9-THC and other cannabinoids in confiscated marijuana from 1980–1997. • More than 25 states have enacted laws legalizing mari- J Forens Sci. 2004;45(1):24-30. 1,3 3. Ramaekers JG, Berghaus G, van Laar MW, Drummer juana to some degree. OH. Dose related risk of motor vehicle crashes after cannabis use: An update. In: Drugs, Driving and Traffic • Cannabis impairs the ability to perform tasks associated Safety. Basel, Switzerland: Birkhauser; 2009:477-499. with driving in a dose-dependent fashion for several 4. Downey LA, King R, Papafotiou K, et al. The effects of hours after using a cannabis-containing product.5,6 cannabis and alcohol on simulated driving: Influences of dose and experience. Accid Anal Prev. 2013;50:879-886. 5. Bondallaz P, Favrat B, Chtioui H, Fornari E, Maeder • Cannabis-associated motor vehicle operation has P, Giroud C. Cannabis and its effects on driving skills. increased fivefold over the past quarter-century, Forensic Sci Int. 2016;268:92-102. especially in states where its use has been legalized or 6. Dubois S, Mullen N, Weaver B, Bedard M. The combined decriminalized.7,8 effects of alcohol and cannabis on driving: Impact on crash risk. Forensic Sci Int. 2015;248:94-100. 7. Couper FJ, Peterson BL. The prevalence of marijuana in • Current methods for determining cannabis-related suspected impaired driving cases in Washington state. intoxication are challenging and difficult to utilize at J Anal Toxicol. 2014;38(8):569-574. the point of need, and may not accurately determine 8. Salomonsen-Sautel S, Min SJ, Sakai JT, Thurstone C, impairment.5,9-12 Hopfer C. Trends in fatal motor vehicle crashes before and after marijuana commercialization in Colorado. Drug and Alcohol Depend. 2014;140:137-144. • Since 1970, cannabis and cannabinoid-containing compounds have been listed by the Drug Enforce- continued on next page ment Administration as a Schedule I Controlled Substance with “no currently acceptable medical use” and the Food and Drug Administration has not

FEB 2018 BULLETIN American College of Surgeons STATEMENTSTATEMENT

approved marijuana as a safe and effective drug for REFERENCES, CONTINUED 13 any indication. 9. Ramaekers JG, Berghaus G, van Laar M, Drummer OH. Dose related risk of motor vehicle crashes after cannabis The ACS therefore supports the following: use. Drug and Alcohol Depend. 2004;73(2):109-119. 10. Ronen A, Gershon P, Drobiner H, et al. Effects of THC on driving performance, physiological state and subjective • Educating the public about safe driving habits and the feelings relative to alcohol. Accid Anal Prev. 2008;40(3):926- risks of recent cannabis use, including co-use with 934. alcohol, medications, or any illicit substances14 11. Hartman RL, Huestis MA. Cannabis effects on driving skills. Clin Chem. 2013;59(3):478-492. • Funding research to determine appropriate medical 12. Bramness JG, Khiabani HZ, Morland J. Impairment due to cannabis and ethanol: Clinical signs and additive cannabis use and restriction for use in conjunction effects. Addiction. 2010;105(6):1080-1087. 15 with motor vehicle operation 13. State marijuana laws in 2016 map. Governing.com. 2016. Available at: www.governing.com/gov-data/state- • Developing evidence-based legislation to deter driving marijuana-laws-map-medical-recreational.html. Accessed while intoxicated in conjunction with reliable point-of- December 19, 2017. 44 | 14. Sewell RA, Poling J, Sofuoglu M. The effect of cannabis care tests to accurately identify cannabis intoxication compared with alcohol on driving. Am J Addictions. or impairment 2009;18(3):185-193. 15. Drug Enforcement Administration. Denial of Petition • Encouraging the comprehensive care of the injured to Initiate Proceedings to Reschedule Marijuana, 81 Fed. patient, including attention to the use of substances Reg 53688. (August 12, 2016) (to be codified at 21 C.F.R. pts. 156). that impair judgment and dexterity, including 16. Schermer CR, Moyers TB, Miller WR, Bloomfield LA. cannabis Trauma center brief interventions for alcohol disorders decrease subsequent driving under the influence arrests. • Researching the effectiveness of brief interventions J Trauma Acute Care Surg. 2006;60(1):29-34. to reduce cannabis-intoxicated driving16 ♦

V103 No 2 BULLETIN American College of Surgeons STATEMENT

Statement on Post-Traumatic Stress Disorder in Adults

The American College of Surgeons (ACS) Committee on Trauma (COT), through its Subcommittee on Injury Prevention and Control, prepared the following Statement on Post-Traumatic Stress Disorder in Adults to educate surgeons and other medical professionals on the significance of post-traumatic stress disorder (PTSD) and the mental health impact of trauma. The ACS Board of Regents approved this statement at its October 2017 meeting in San Diego, CA.

REFERENCES 1. Holbrook TL, Hoyt DB, Coimbra R, Potenza B, Sise M, he ACS recognizes the following facts: Anderson JP. Long-term posttraumatic stress disorder T persists after major trauma in adolescents: New data • PTSD is a state of anxiety following a physical or psy- on risk factors and functional outcome. J Trauma. 2005;58(4):764-769. chological traumatic incident that includes symptoms 2. Shih RA, Schell TL, Hambarsoomian K, Belzberg of extreme fear, anxiety, insomnia, helplessness, and H, Marshall GN. Prevalence of posttraumatic stress | 45 recurring memories that may result in avoidance of disorder and major depression after trauma center people, places, or objects associated with the event. hospitalization. J Trauma. 2010;69(6):1560-1566. Symptoms lasting longer than 30 days after the event 3. Zatzick D, Jurkovich GJ, Rivara FP, et al. A national U.S. study of posttraumatic stress disorder, are considered to be PTSD. depression, and work and functional outcomes after hospitalization for traumatic injury. Ann Surg. • Epidemiologic investigation at U.S. trauma centers 2008;248(3):429-437. demonstrates that approximately 20–40 percent of 4. Powers MB, Warren AM, Rosenfield D, et al. injured trauma survivors experience high levels of Predictors of PTSD symptoms in adults admitted to a level I trauma center: A prospective analysis. J Anxiety PTSD and/or depressive symptoms during the year Disord. 2014;28(3):301-309. following injury.1-3 5. Warren AM, Foreman ML, Bennett MM, et al. Posttraumatic stress disorder following traumatic • A series of investigations now demonstrates a strong injury at 6 months: Associations with alcohol use and relationship between the symptoms of PTSD, depres- depression. J Trauma. 2014;76(2):517-522. 1-3 6. Alarcon LH, Germain A, Clontz AS, et al. Predictors sion, and functional impairments after injury. of acute posttraumatic stress disorder symptoms following civilian trauma: Highest incidence • Victims of interpersonal violence have an increased and severity of symptoms after assault. J Trauma. risk of PTSD.4-7 2012;72(3):629-635. 7. Resse C, Pederson T, Avila S, et al. Screening for traumatic stress among survivors of urban trauma. The ACS supports efforts to promote, enact, and J Trauma Acute Care Surg. 2012;73(2):462-468. sustain legislation and policies that encourage: 8. Wong EC, Schell TL, Marshall GN, Jaycox LH, Hambarsoomians K, Belzberg H. Mental health service • Implementing a screening/referral protocol into the utilization after physical trauma: The importance of care of trauma patients using an evidence-based tool, physician referral. Med Care. 2009;47(10):1077-1083. such as the Primary Care PTSD screen (PC-PTSD), continued on next page PTSD Checklist–Civilian version (PCL-C), and integration of the protocol into the electronic health record8-10

FEB 2018 BULLETIN American College of Surgeons STATEMENT

• Implementing hospital-based violence intervention REFERENCES, CONTINUED programs with a mental health component in hospi- 9. Hanley J, de Roon-Cassini T, Brasel K. Efficiency of a tals that care for those individuals injured as a result four-item posttraumatic stress disorder screen in trauma of interpersonal violence11 patients. J Trauma. 2013;75(4):722-727. 10. Russo J, Katon W, Zatzick D. The development of a • Enhanced research funding to better understand population based screening procedure for PTSD in acutely injured hospitalized trauma survivors. Gen Hosp Psych. PTSD and depression following injury, and to iden- 2013;35(5):485-491. tify best methods of alleviating the symptoms and 11. Purtle J, Dicker R, Cooper C, et al. Hospital-based their sequelae ♦ violence intervention programs save lives and money. J Trauma Acute Care Surg. 2013;75(2):331-333.

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V103 No 2 BULLETIN American College of Surgeons STATEMENT

Statement on Post-Traumatic Stress Disorder in Pediatric Trauma Patients

The American College of Surgeons (ACS) Committee on Trauma (COT), through its Subcommittee on Injury Prevention and Control, prepared the following Statement on Post-Traumatic Stress Disorder in Pediatric Trauma Patients to educate surgeons and other medical professionals on the significance of post-traumatic stress disorder (PTSD) and the mental health impact of trauma in children. The ACS Board of Regents approved this statement at its October 2017 meeting in San Diego, CA.

REFERENCES 1. American Psychiatric Association: Diagnostic and The ACS recognizes the following facts: Statistical Manual of Mental Disorders (DSM-5®), Fifth Edition. Arlington, VA: American Psychiatric • PTSD is a state of emotional and behavioral disorder that Association; 2013. can result from witnessing or experiencing an event involv- 2. Holbrook TL, Hoyt DB, Coimbra R, Potenza B, Sise M, Anderson JP. Long-term posttraumatic | 47 ing actual or possible death, serious injury, or physical or stress disorder persists after major trauma sexual violence. in adolescents: New data on risk factors and functional outcome. J Trauma. 2005;58(4):764-769. • PTSD is defined as a set of four symptom clusters that 3. Shih RA, Schell TL, Hambarsoomian K, Belzberg include intrusive memories, thoughts, or sensations relat- H, Marshall GN. Prevalence of posttraumatic stress disorder and major depression after trauma center ing to the event; avoidance of people, places, objects, or hospitalization. J Trauma. 2010;69(6):1560-1566. sensations associated with the event; negative alterations 4. Zatzick D, Jurkovich GJ, Fan MY, et al. in mood and thought patterns; as well as hyperarousal, Association between posttraumatic stress and anxiety, and unhealthy reactivity to stress. Symptoms last- depressive symptoms and functional outcomes ing longer than 30 days after the event are considered to be in adolescents followed up longitudinally after injury hospitalization. Arch Ped Adolescent Med. PTSD, whereas symptoms observed soon after the event 2008;162(7):642-648. (lasting at least three days and up to 30 days) are considered 5. Holbrook TL, Hoyt DB, Coimbra R, Potenza B, acute stress disorder (ASD).1 Sise M, Anderson JP. High rates of acute stress disorder impact quality of life outcomes in injured • Epidemiologic investigation at U.S. trauma centers demon- adolescents: Mechanism and gender predict acute stress disorder risk. J Trauma. 2005;59:1126-1130. strates that approximately 20–40 percent of injured trauma 6. Alarcon LH, Germain A, Clontz AS, et al. survivors experience high levels of PTSD and/or depressive Predictors of acute posttraumatic stress disorder symptoms in the year following injury.2-4 symptoms following civilian trauma: Highest incidence and severity of symptoms after assault. • A relationship has been found between the symptoms J Trauma. 2012;72(3):629-635. 7. Resse C, Pederson T, Avila S, et al. Screening for of PTSD, depression, and functional impairment, as traumatic stress among survivors of urban trauma. well as quality of life during the first year after injury in J Trauma Acute Care Surg. 2012;73(2):462-468. adolescents.4,5 continued on next page • Victims of interpersonal forms of trauma, such as domestic or community violence and child physical and sexual abuse, have increased risk of developing PTSD.6-8

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• Well-disseminated, evidence-based behavioral interven- REFERENCES, CONTINUED tions exist for treating pediatric PTSD, which can serve as resources for children and adolescents who score positive 8. Kassam-Adams N, Marsca ML, 9,10 Hildenbrand A, Winston F. Posttraumatic stress on screening protocols. following pediatric injury update on diagnosis, risk factors and intervention. JAMA Pediatrics. The ACS supports efforts to promote, enact, and sus- 2013;167(12):1180-1187. tain legislation and policies that encourage the following: 9. Gillies D, Taylor F, Gray C, O’Brien L, D’Abrew N. Psychological therapies for the treatment of post‐ traumatic stress disorder in children and adolescents • Implementing a screening/referral protocol into the care of (Review). Evid Based Child Health. 2013;8(3):1004-1116. pediatric trauma patients for ASD/PTSD using an evidence- 10. de Arellano MA, Lyman DR, Jobe-Shields L, et al. based tool, such as www.HealthCareToolbox.com (National Trauma-focused cognitive-behavioral therapy for Child Traumatic Stress Network), and integration of the children and adolescents: Assessing the evidence. 8,11-15 Psychiatr Serv. 2014;65(5):591-602. protocol into the electronic health record. 11. Gaines BA, Hansen K, McKenna C, et al. Report from the Childress Summit of the Pediatric Trauma • Implementing hospital-based violence intervention pro- Society, April 22–24, 2013. J Trauma Acute Care Surg. 48 | grams with a mental health component specific for children 2014;77(3):504-509. in hospitals that care for those patients affected by inter- 12. Wong EC, Schell TL, Marshall GN, Jaycox LH, 16 Hambarsoomians K, Belzberg H. Mental health personal violence. service utilization after physical trauma: The importance of physician referral. Med Care. • Enhanced research funding to better understand PTSD and 2009;47(10):1077-1083. other trauma-related disorders in children following injury, 13. Kassam-Adams N, García-España F, Marsac ML, and to identify best methods of alleviating the symptoms et al. A pilot randomized controlled trial assessing secondary prevention of traumatic stress integrated and their sequelae. into pediatric trauma care. J Trauma Stress. 2011;24(3):252-259. • Parents of trauma-exposed children also may experience 14. Kenardy JA, Cox CM, Brown FL. A web-based early emotional and behavioral consequences related to the event, intervention can prevent long-term PTS reactions which may influence children’s recovery; thus, attending in children with high initial distress following accidental injury. J Trauma Stress. 2015;28(4):366-369. to the parents’ needs also is critical. ♦ 15. Zatzick D, Russo J, Lord SP, et al. Collaborative care intervention targeting violence risk behaviors, substance use, and posttraumatic stress and depressive symptoms in injured adolescents: A randomized clinical trial. JAMA Pediatr. 2014;168(6):532-539. 16. Purtle J, Dicker R, Cooper C, et al. Hospital-based violence intervention programs save lives and money. J Trauma Acute Care Surg. 2013;75(2):331-333.

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Regulatory burden reduction

by Lauren Foe, MPH

ealth care providers are with stakeholders to discuss recommendations for reducing or inundated with a growing physician burden and regulatory eliminating these encumbrances. Hnumber of regulatory relief. To further define which requirements promulgated regulations are most burdensome by various federal agencies. and should be modified, CMS What burdens are associated Although these policies are launched the Patients over with the global codes data broadly intended to ensure that Paperwork initiative, under collection process, and patients receive care that meets which agency officials will visit what recommendations quality and safety standards, physician practices across the does the ACS have for providers are confronted country to gather information on easing these demands? with the burden of regulatory the administrative duties required In July 2017, CMS began compliance. Surgeons find of health care professionals. collecting data on postoperative themselves spending more time The American College visits furnished in the 10- and completing paperwork and other of Surgeons (ACS) has long 90-day global period from tasks to satisfy administrative supported policies that enhance physicians who are part of requirements, taking away time patient care, reduce regulatory groups of 10 or more providers with patients. The regulatory burden, and streamline clinical and who live in one of nine | 49 burdens on surgeons and their workflow. Over the past year, the specified states. Under this practices add hurdles to providing ACS Division of Advocacy and mandatory reporting policy, necessary care and increase Health Policy has positioned the which is intended to allow spending on nonclinical activities. College at the forefront of the CMS to gather enough data In January 2017, the Trump regulatory relief movement. The on postoperative visits for the Administration issued Executive ACS is an active participant in all purpose of revaluing surgical Order 13771, which seeks to regulatory reform events hosted services starting in 2019, “manage the costs associated with by HHS and CMS, and provides physicians must report one the governmental imposition of feedback to federal leaders Current Procedural Terminology private expenditures required on the impact of unnecessary (CPT) code 99024 for each to comply with Federal regulations on the provision of postoperative evaluation and regulations.”* Following the essential surgical services. In management (E/M) visit release of this order, the U.S. early 2018, the ACS launched provided in the global period.† Department of Health and its Stop Overregulating My This reporting requirement Human Services (HHS) and the OR [operating room] initiative, disproportionately affects Centers for Medicare & Medicaid which describes specific actions physicians who provide global Services (CMS) began meeting that should be taken to reduce services. CMS failed to address burdens and enable surgeons to numerous implementation *Trump DJ. Executive order: 13771: Reducing reinvest their time and resources issues or allow adequate time Regulation and Controlling Regulatory in patients. More information for provider education before Costs. January 30, 2017. Available at: www. about the initiative is available the agency began collecting gpo.gov/fdsys/pkg/FR-2017-02-03/pdf/2017- 02451.pdf. Accessed December 28. on the ACS website at facs.org. postoperative visit data. †All specific references to CPT codes and This column provides an Furthermore, CMS has not descriptions are ©2017 American Medical overview of the regulations assured providers that all claims Association. All rights reserved. CPT and CodeManager are registered trademarks that are most onerous for submitted with the required data of the American Medical Association. surgeons and describes ACS will be captured and counted,

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The ACS has long supported has not shared a comprehensive starting in 2019, the Merit-based plan for data validation, nor has Incentive Payment System policies that enhance patient provided details on how the (MIPS) performance threshold care, reduce regulatory data will be used in the future. be set at the mean or median burden, and streamline The ACS urged CMS to delay of the composite performance the collection of global codes scores for all MIPS-eligible clinical workflow. Over the data until the agency corrects physicians, thereby penalizing past year, the ACS Division outstanding implementation approximately half of Part issues, tests the reporting B providers. It is purely of Advocacy and Health and data collection process, speculative to consider how Policy has positioned the and shares a plan for data CMS will implement the validation so that providers can rewards or penalties once the College at the forefront of the confirm that submitted data threshold is set. One option regulatory relief movement. are received and connected would include a graduated to the correct code. CMS scale for rewards or penalties. began data collection without A graduated scale would mean 50 | addressing these concerns. that physicians clustered near The College asserts that the mean/median would see CMS should not have imposed less impact than physicians this burden on physicians until who are further from the the data reporting process mean/median. In such a had been tested and proven scenario, those furthest from to be effective. Without the mean/median would sufficient preparation, physician stand to gain or lose the most. education, or a plan for data Those details will remain validation, the information unclear until CMS finalizes collected is inherently flawed its benchmarking policy. and of low statistical quality. The MIPS benchmarking Given these unresolved issues, system is inadequate the ACS recommends that for measuring physician CMS avoid using such data to performance and lacks rigor revalue global services in 2019. in common data aggregation, common data analytics, and reporting. To accurately What burdens are associated compare physicians’ MIPS data, with MIPS benchmarking, CMS must use reliable methods, and what recommendations including standardized data does the ACS have for definitions, risk adjustment/ easing these demands? data analytics, data The Medicare Access and CHIP ascertainment methods, and (Children’s Health Insurance data normalization methods. Program) Reauthorization Act The ACS recommends that CMS (MACRA) of 2015 requires that, provide additional flexibility

V103 No 2 BULLETIN American College of Surgeons WHAT SURGEONS SHOULD KNOW ABOUT...

A 2017 ACS survey of nearly 300 Fellows and practice managers indicated that, on average, a surgical practice receives approximately 37 PA requests per surgeon per week, taking providers and staff 25 hours—the equivalent of three business days—to complete.

in its benchmarking policy A 2017 ACS survey of nearly complex cases or to providers and allow more time to test 300 Fellows and practice with ordering patterns that and implement a statistically managers indicated that, on differ substantially from their valid measure framework that average, a surgical practice colleagues’ after adjusting for follows care across an episode. receives approximately 37 patient population. PA should To address the flawed PA requests per surgeon per not be required for services benchmarking process and week, taking providers and or supplies that are standard lack of MIPS measures that staff 25 hours—the equivalent for a specific condition or that are relevant to surgeons, of three business days—to previously have been approved the College is developing complete. Many practices must as part of a patient’s care a comprehensive measure hire full-time employees who treatment plan. A reduction framework inclusive of high- exclusively process PA requests, in the variation and scope value process measures across as the task of fulfilling all PA of PA requirements across an episode of care, coupled requirements, which often insurers could drastically with complementary patient- include lengthy phone calls reduce administrative costs reported outcome and patient- and submission of voluminous to surgeons and ensure reported experience measures. medical records, is too tedious prompt delivery of care. | 51 This framework provides an for physicians and other staff to To better integrate PA opportunity to accurately perform while simultaneously processes into the clinical measure and compare surgeon interacting with patients. In workflow, the ACS also performance across the phases addition, there is little to no recommends that PA requests, of surgical care in alignment consistency across insurers’ PA decisions, and appeals with a patient’s clinical flow. programs, forcing physicians processes be automated and staff to spend significant through uniform electronic time reviewing each insurer’s transaction portals for What burdens are associated PA criteria and processes. medical and pharmacy with prior authorization, The administrative burdens services. To ensure that and what recommendations associated with PA requirements patients have timely access does the ACS have for often result in delayed or to care, PA decisions should easing these demands? interrupted treatment and can be transmitted by an insurer Prior authorization (PA) is lead to severe, life-threatening to a provider through the a process through which health outcomes. Many patients appropriate electronic portal approval for coverage of a remain in the hospital while within 24 hours for urgent medical service or supply item awaiting PA for necessary care and 48 hours for non- must be obtained by a health services or supplies that would urgent care. It is crucial that care provider before the service allow them to be discharged PA information be entered or item may be furnished to earlier, which puts them at into electronic platforms a patient. PA requirements risk for complications. shared by physicians, are overused and applied The ACS asserts that administrative staff, and to all physicians, regardless PA requirements should be insurers to streamline payor- of their ordering patterns standardized across all insurers provider communication and or adherence to evidence- and that such requirements reduce the time and resources based clinical guidelines. should be applied only to practices devote to PA.

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remove redundancies, and align a patient’s status. The ACS What burdens are associated use with EHRs. The College recommends that CMS review with E/M documentation urges CMS to convene a group this policy to determine if waiving guidelines, and what of physicians, including surgeon the three-day stay requirement recommendations does representatives, to explore the would reduce Medicare costs the ACS have for easing role of medical complexity, and maintain the quality of care these demands? risk of medical decision provided to beneficiaries. The The E/M documentation making, and other factors that College supports a system where guidelines were developed in incorporate aspects of a patient’s patients are assured that their 1995 when medical records overall health status into a care and financial obligations will were on paper. Back then, new weighting of the E/M not be adversely affected by their these guidelines created documentation requirements. patient status and length of stay. accountability to describe the level of E/M codes selected for the services billed. In the What burdens are associated What burdens are associated digital electronic health record with the skilled nursing facility with the Two-Midnight Rule, 52 | (EHR) era, these guidelines three-day stay requirement, and what recommendations are easily proliferated, creating and what recommendations does the ACS have for voluminous medical records. does the ACS have for easing these demands? The result is extraneous notes easing these demands? Under the Two-Midnight of little or no value, including The skilled nursing facility Rule, inpatient stays of less the perpetuation of errors (SNF) benefit is for Medicare than two midnights after and misinformation. The patients who require a short- hospital admission are not EHR has become a hindrance term intensive stay in a SNF. considered medically necessary. to care and communication Beneficiaries must have a prior The implementation of this among providers. inpatient hospital stay of at policy, which was intended Although it is important least three consecutive days to reduce the number of that physicians document to be eligible for Medicare short hospital inpatient stays their work, the current Part A coverage of SNF care. If a and long outpatient stays, system requires unnecessary beneficiary is not admitted to a has resulted in negative information, sometimes hospital as an inpatient for at least consequences for physicians obscuring relevant and three days, Medicare will deny and Medicare beneficiaries. necessary data for patient care. Part A payment for stays at a SNF. The Two-Midnight Rule has The ACS recommends that CMS This requirement compromises not resulted in a significant review and modernize E/M some patients’ access to necessary reduction in the number of guidelines to reduce burdens, post-hospital care coverage under long outpatient stays billed to Medicare and contributes to Medicare, leading to higher ‡Medicare Payment Advisory Commission. avoidable hospital admissions. costs and greater limitations Report to the Congress: Hospital short- stay policy issues. June 2015:173-204. The three-day stay for beneficiaries seeking SNF Available at: http://medpac.gov/docs/ requirement assigns an arbitrary care following an outpatient default-source/reports/june-2015-report- time frame to patient care stay under observation status.‡ to-the-congress-medicare-and-the-healthcare-delivery-system.pdf?sfvrsn=0. and detracts from physicians’ The Two-Midnight Rule Accessed December 28, 2017. clinical judgment in determining has failed to create uniform

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The ACS recommends that CMS develop a standardized approach for audit contractors to notify providers of a review, request medical records, inform providers of the specific reason a claim is denied, and clearly state a provider’s appeal rights.

criteria for inpatient status or eliminate requirements for Medicare and Medicaid substantially reduce the number providers to regularly recertify audits are a great source of of long outpatient stays for a patient’s condition when the frustration and expense for Medicare beneficiaries. The patient is diagnosed with a surgeons. Physicians need a ACS recommends that CMS chronic illness. Authorization single, transparent, consistent, rescind the Two-Midnight Rule for certain types of medical and fair review process to in favor of physicians’ clinical supplies should also be reduce administrative burdens. judgment and the medical standardized across suppliers so The ACS recommends that necessity of a hospital stay. that providers are not required CMS develop a standardized to recertify a patient’s need approach for audit contractors for such supplies each time a to notify providers of a review, What burdens are associated patient switches supply brands. request medical records, inform with Medicare documentation, The ACS also recommends providers of the specific reason certification, and recertification that physicians be allowed to a claim is denied, and clearly requirements, and what authorize their clinical staff, state a provider’s appeal rights. recommendations does the ACS such as nurse practitioners Expenditures, such as have for easing these burdens? and physician assistants, printing and shipping fees for | 53 Medicare documentation to complete certification providers who receive clinical policies set forth redundant forms on their behalf. documentation requests from requirements for verifying auditors, are high. The College physician orders, delaying patient urges CMS to require auditors access to services and equipment. What burdens are to reimburse providers for the CMS only will pay for covered associated with Medicare medical records submitted. services if physicians certify and program integrity, and Physicians who win an recertify medically necessary what recommendations appeal of an audit should be care and resources, including does the ACS have for reimbursed the full cost of hospital stays, wheelchairs, easing these demands? complying with the review colostomy supplies, diabetic Physicians are facing an process by the auditing entity. testing supplies, physical therapy, increasing amount of and home health and hospice prepayment and postpayment services. These documentation audits from CMS and its What burdens are requirements are redundant and contractors. These audits associated with medical require physicians to review often are voluminous translator services, and lengthy patient charts to confirm and not completed in a what recommendations orders that they have already timely manner, depriving does the ACS have for certified as medically necessary. physicians of reimbursement easing these demands? The ACS recommends that for extended periods. The The HHS Office of Civil CMS take a more targeted number of reviews and types Rights requires all physicians approach to the enforcement of of contractors are confusing, who receive payments from documentation and certification add unwarranted physician any federal health program requirements. The College burden and unnecessary to provide access to verbal or urges CMS to standardize and costs, and disrupt and distract written translation services for streamline this process and from delivering care. individuals with disabilities

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or limited English proficiency. a patient to interpret or across EHRs, mobile devices, HHS does not pay for medical facilitate communication. registries, and patient clouds, translators and places the the ACS recommends responsibility on physicians that HHS establish an to offer translation services What burdens are associated interoperability framework and at no cost to patients. Hiring with the exchange of digital collaborate with the physician translators who are fluent in health information, and community, along with other the appropriate dialect and what recommendations stakeholders, to determine are familiar with medical does the ACS have for best practices for leveraging terminology is expensive, easing these demands? digital health information particularly when interpreters The clinical care model to improve health, enhance impose a time minimum for is growing increasingly care, and optimize costs. their services or charge travel intricate, with a vast amount In addition, the College and cancellation fees. Qualified of information that must has partnered with Health medical translators can cost interoperate across different Level Seven and the Health physicians hundreds of dollars electronic platforms, thereby Services Platform Consortium 54 | per patient visit, and the cost of creating a high demand for to create national standards retaining a qualified translator the exchange of digital health for the exchange, integration, often exceeds the total payment information in a convenient and and retrieval of digital health for the treatment provided. usable format. While patients information. Once these The ACS believes that federal receive care longitudinally standards are complete, the funding should be provided to over time, and not always in ACS recommends that CMS physicians for the purposes of one facility or under one EHR, adopt them as a mandatory hiring medical translators to existing digital information component of EHR certification ensure continued access to care exchange processes do not to promote interoperability for patients with disabilities effectively track patients across health care providers, or limited English proficiency. over time and space. facilities, and insurers. The College recommends that Without access to For more information about the cost of medical translator interoperable and usable digital regulatory requirements or the services be considered part health information, providers College’s administrative burden of the cost of care delivery spend hours documenting and reduction efforts, contact Lauren and asks that CMS provide searching for information, which Foe, ACS Regulatory Affairs reimbursement for CPT code is extremely burdensome and Associate, at [email protected]. ♦ T1013, sign language or oral detracts from patient care. The interpretive services, per 15 minutes. current digital environment To further reduce these cannot deliver the information costs to physicians, the ACS physicians need to develop even urges the HHS Office of a basic treatment plan, and Civil Rights to revise the surgeons are frustrated with definition of a “qualified an inefficient clinical workflow interpreter” to allow the use that reduces time with patients. of an adult, such as a relative To enable digital health or friend, accompanying information interoperability

V103 No 2 BULLETIN American College of Surgeons FROM RESIDENCY TO RETIREMENT

Race and residency training in the post-Charlottesville era

by Allison N. Martin, MD, MPH

aturally, I was on edge does not intimidate me. This was that has always been a part when I heard about the true when I began my surgical of American history. Nalt-right rally scheduled training several years ago, The same stigma that in our town last summer. I long before white supremacists I confronted as a child in rural was on call for both general descended upon our town. I Kentucky has followed me North surgery and trauma during am no stranger to being the and South, through the halls the weekend of the August 12, only black person in a room. of elite academic institutions, 2017, Unite the Right rally. I grew up in a rural and into the operating rooms Every available member of our community in Kentucky that (ORs) and clinics where I now | 55 surgical residency program was more than 90 percent train as surgical resident. I was was present, whether on call or white. Whether being called naïve to think that becoming not, and assembled into trauma a “nigger” for accidentally a physician would spare me teams. When we received notice bumping into a fellow classmate from the stigma associated with that violence was occurring in the hallway or losing the my complexion. My academic in downtown Charlottesville, opportunity to be one of achievements did not matter VA, I joined an entire army of the first black valedictorians to the nurse who ordered me hospital staff of all backgrounds at my high school due to a to retrieve the catheter and as we rallied together, braced last-minute policy change, blanket, thinking that I was an ourselves for the response, throughout my life I have OR tech, yet soon found out and did what we do best— been reminded covertly and that I was the resident physician care for the sick and injured. overtly that I am black. taking care of our shared patient. There were no voices of hate As a high school student I experience a brief moment of or frustration from the medical volunteering at my local tension, uncertainty, and doubt staff that day, only effective community hospital, I was sent that seems to pervade the room communication to respond to comfort newborns when when a patient is surprised and coordinate care for those members of the Ku Klux Klan that his or her physician is in need. It was one of the most (KKK) from a neighboring young, female, and black. In inspiring moments of my life. county would come have their addition to the normal stresses babies delivered at our hospital. and challenges of residency, I never feared these individuals my colleagues from different Earlier experiences with race who proudly displayed their gender, ethnic, religious and Charlottesville’s racial shaved heads and swastika other underrepresented minority homogeneity is no different tattoos, but they served as a groups face hurtful acts of than that of many U.S. towns visible reminder of the overt ignorance from both colleagues and cities, and its whiteness racism and discrimination and patients. These little

FEB 2018 BULLETIN American College of Surgeons FROM RESIDENCY TO RETIREMENT

instances build the perception problem has been longstanding When we received notice of intolerance, no matter how in our town, and it did not start strong the message of diversity the weekend of the rally. that violence was occurring and inclusion is broadcast for Though I had a solidly in downtown Charlottesville, the public’s consumption. middle-class upbringing and VA, I joined an entire army have experienced many forms of privilege in my life, the of hospital staff of all Starting a discussion America that I know and the backgrounds as we rallied Studies that examine challenges Charlottesville that I know have facing minority trainees rarely not always been comfortable together, braced ourselves have been explored; however, with minorities existing in this for the response, and did several qualitative studies have predominantly white space. what we do best—care started the difficult work of Now it is my job to stand up 56 | describing these experiences.1,2 and tell people why it matters for the sick and injured. Chief among issues identified by that trainees of color are here black trainees include the simple and why it is important that fact that being a black trainee we stay. We have not and may in the U.S. makes you highly never be a post-racial or color- visible. By nature, trainees of blind society. We can, however, color stand out, which can make be present in the moment. We them feel more vulnerable and can recognize suffering as a prone to criticism.1 In the months universal phenomenon. We following the rally and counter- can encourage discourse where protest, I have been touched by before there existed only silence. the unity and support from the I want my fellow trainees, Charlottesville community and particularly junior residents my colleagues. Fellow trainees and medical students, to know have come forward to share that I am here for them and instances where they have been that many in their community openly discriminated against both want and need them to be either in our community or present, sharing their knowledge within the hospital. Instances and their talents. This is a where some patients have refused duty I am happy to uphold. care from one of my non-white Going forward, we all colleagues have come to light. must recognize this problem I have heard the groans of staff will not fade away. Leaders of members when a non-English the alt-right movement have speaking patient presents for already vowed to return to evaluation in clinic. These Charlottesville, and stories of examples demonstrate that this rallies elsewhere have become

V103 No 2 BULLETIN American College of Surgeons FROM RESIDENCY TO RETIREMENT

I appeal to all of my friends and colleagues at this critical time: we cannot afford for you to treat this incident as the fad or hashtag of the moment.

widespread. Although I was real, and it is present here. You • Formal and structured not shocked that a group of witnessed it on your doorstep. programs for mentoring and white supremacists, neo- career development for all Nazis, and KKK members residents, which may ensure were planning to rally in our A path forward that opportunities that town, I was surprised at how Very little has been written encourage pursuit of research, some individuals have reacted. regarding how to best confront resident leadership activities, “How could this happen here?” challenges faced by trainees and academic development many have asked. I cannot say I of color, and almost zero data are offered in a more equitable wonder the same thing. There are available regarding how fashion to all trainees. is a veil of discrimination and or whether this experience Mentorship and research during racial divide that was present in differs for surgical trainees training have been shown to this town long before I arrived. versus trainees in nonsurgical influence the pursuit of an I appeal to all of my friends training programs. Butler and academic career, an important and colleagues at this critical colleagues demonstrated a finding given the continued | 57 time: we cannot afford for you profound discrepancy in the underrepresentation of physicians to treat this incident as the fad number of underrepresented of color in academic medicine.3,4 or hashtag of the moment. We minorities among U.S. surgical cannot go back to our respective residents, with only 4.7 percent • Actively shaping a programmatic corners and proceed with black residents compared and institutional environment business as usual. You need to with 64.4 percent white that encourages discussion and stand up to white supremacy in residents. Furthermore, blacks recognition of “racial fatigue,” all its forms, whether it appears represent only 2.9 percent of which may include creating in the form of Nazi imagery U.S. academic surgeons.3,4 opportunities for trainees of color or in colloquial conversation The limited body of research to have planned social support through a joke or stereotype. that does exist on this topic in both formal and informal Your protest must be greater suggests a few particular actions settings. Specific institutional and more forceful than a that might enhance the training mechanisms to respond to candlelight vigil; words and environment for black residents. instances of racism and bigotry actions that oppose this hatred These recommendations experienced by trainees should must become a part of your include the following: be well-defined and a faculty daily life. When a friend or champion designated.2 colleague comes to you after a • Acknowledgement by majority patient or co-worker has said faculty and residency leadership • Coordination of an institutional something denigrating and of how residents’ race may action plan to advocate for insulting to them, take time to influence their experience as faculty, staff, and trainees facing listen and understand rather surgical trainees. This recognition discrimination from patients who than dismiss it as being all in may help combat the sense of exhibit discriminatory behavior. their head. If the events from vulnerability associated with This protocol should include the Unite the Right rally reveal being an underrepresented both a pathway for reporting anything, it is that racism is minority in surgical training.1,5 this inappropriate behavior and

FEB 2018 BULLETIN American College of Surgeons FROM RESIDENCY TO RETIREMENT

Just as the caretakers of Monticello have sought to unify the complicated pieces of Thomas Jefferson’s history intertwined with the tales of slaves who lived and suffered under the yolk of slavery on top of the hill that overlooks Charlottesville, we must rebuild our image of surgical training.

designation of a core group of means recommitment to and REFERENCES individuals who are available to redoubling of efforts aimed at respond to these issues on behalf recruiting both black faculty and 1. Liebschutz JM, Darko GO, Finley EP, Cawse JM, Bharel M, of the institution. trainees. It means formulating Orlander JD. In the minority: a targeted and specific plan for Black physicians in residency and Implementing these steps is increasing diversity in surgical their experiences. J Natl Med Assoc. not going to be easy. Just as the training programs, and this 2006;98(9):1441-1448. caretakers of Monticello have is a step that has already been 2. Nunez-Smith M, Curry LA, Bigby J, Berg D, Krumholz HM, sought to unify the complicated taken at the University of Bradley EH. Impact of race on the pieces of Thomas Jefferson’s Virginia and in the department professional lives of physicians of history intertwined with the of surgery, specifically. African descent. Ann Intern Med. tales of slaves who lived and After departmental 2007;146(1):45-51. suffered under the yolk of debriefings in the wake of this 3. Butler PD, Longaker MT, Britt 58 | LD. Major deficit in the number slavery on top of the hill that tragedy, I know now more than of underrepresented minority overlooks Charlottesville, we ever that I am not the only one academic surgeons persists. Ann must rebuild our perceptions of to experience racism, sexism, Surg. 2008;248(5):704-711. race and how it impacts surgical and bigotry at work. It happens 4. Julien JS, Lang R, Brown TN, et training. The previously held often—more than many people al. Minority underrepresentation in academia: Factors impacting assumption that our city and are comfortable admitting. careers of surgery residents. others like it is a safe zone Conversations surrounding J Racial Ethn Health Disparities. for students and learners of race and ethnicity are never 2014;1(4):238-246. all backgrounds has been going to be easy, but if we do 5. Wong RL, Sullivan MC, Yeo HL, effectively shattered. As we not use this opportunity to Roman SA, Bell RH, Jr., Sosa JA. Race and surgical residency: Results rebuild from the tragedy try, we may never again get from a national survey of 4339 U.S. resulting from the rally, it is the chance. Standing firm and general surgery residents. Ann Surg. important to do so in unity. speaking up is the only way 2013;257(4):782-787. Training programs with we can move forward. ♦ predominantly white, male leadership must create an environment where trainees Acknowledgements from all backgrounds can The author would like to thrive and learn. Other acknowledge Charles Friel, MD, authors have written about the FACS, and Victor Zaydfudim, MD, importance of black trainees MPH, FACS, for their generous working in an environment edits, contributions, and support in where they can receive the authoring of this manuscript. encouragement and affirmation from all faculty members.1 Creating a better workspace for minority trainees, therefore,

V103 No 2 BULLETIN American College of Surgeons ACS CLINICAL RESEARCH PROGRAM

Surgical management of ADH, ALH, and LCIS

by Diana Dickson-Witmer, MD, FACS; Amy C. Degnim, MD, FACS; Isabelle Bedrosian, MD, FACS; and Judy C. Boughey, MD, FACS

he most important the terminal ductal lobular unit magnetic resonance imaging implication of finding involved (greater for LCIS than (MRI), especially in women with Tatypical ductal hyperplasia ALH). Risk of breast cancer— prior history of cancer.9 LCIS with (ADH) or lobular neoplasia— invasive and ductal carcinoma comedo-necrosis and pleomorphic atypical lobular hyperplasia in situ (DCIS)—is increased for LCIS have upgrade rates as high (ALH) or lobular carcinoma in both, approximately a four- to as 40 percent to invasive cancer situ (LCIS)—is that the patient fivefold increased risk for ALH and should be excised.10-11 is at a significantly increased and eight- to ninefold increased lifetime risk of developing breast risk for LCIS, with both breasts cancer (1–2 percent per year for at increased risk. Recent ADH ADH or ALH, and approximately estimates of absolute risk suggest ADH and low-grade DCIS have 2 percent per year for LCIS).1-3 1–2 percent per year for ALH and an identical histologic phenotype, | 59 These patients should be 2 percent per year for LCIS.1-5 and the distinction is made thoroughly informed of breast Upgrade rates for ALH primarily on the quantity of cancer risk and appropriate and classic LCIS on CNB in atypia present. Because the linear surveillance and risk-reduction retrospective studies were wide- extent of atypia is a criterion strategies, which should include ranging in early studies, but for distinction between ADH consideration of prevention more contemporary studies and DCIS, and because multiple therapy, which has been shown with consistent large core studies have shown an upgrade to reduce risk of breast cancer biopsies demonstrate single-digit rate of 10–30 percent for ADH development by as much as upgrade rates for pure lobular on CNB, surgical excision is 70 percent for women with neoplasia without mass lesion the well-established standard of these high-risk breast lesions.2 on imaging. Recent studies that care.12 Because surgical excision For the surgeon, another distinguish ALH from LCIS is costly and is a burden on the important issue is when to show higher upgrade rates for patient, ongoing research is surgically excise an area of LCIS (7–28 percent) compared aimed at identifying a subset ADH or lobular neoplasia with ALH (0–9 percent).6-8 of ADH with lower upgrade found on core needle biopsy Thus, the preponderance of rates, where excisional biopsy (CNB) to evaluate for potential evidence indicates that for patients might safely be omitted. Several upstaging to malignancy. without mass lesions and pure studies have evaluated factors ALH on CNB, routine excision associated with upgrade in an is not required; for patients with attempt to identify a subset with Lobular neoplasia: pure LCIS (no mass lesion), low risk of upgrade.13,14 Common ALH and LCIS excision should be considered factors identified across these Lobular neoplasia is a term in the patient’s clinical context. studies include: no mass lesion, that includes both ALH and One study has noted higher removal of a large majority (at classic LCIS, the distinction upgrade rates for lobular neoplasia least 50 percent) of the lesion being only the percentage of identified with screening seen mammographically, no

FEB 2018 BULLETIN American College of Surgeons ACS CLINICAL RESEARCH PROGRAM

TABLE 1. EXCISIONAL BIOPSY RECOMMENDATIONS CNB finding Excisional biopsy recommendation ALH with concordant imaging Not recommended Classic LCIS with concordant imaging Consider excision Classic LCIS identified on MRI Recommended LCIS with comedo-necrosis Recommended Pleomorphic LCIS Recommended ADH Recommended

necrosis, and ADH involving only one REFERENCES or two terminal duct lobular units. 1. Degnim AC, Dupont WD, Radisky DC, et al. Extent of atypical For women with ADH who met hyperplasia stratifies breast cancer risk in 2 independent cohorts of these criteria, upgrade rates were only women. Cancer. 2016;122(19):2971-2978. 3–5 percent. However, prospective 2. Coopey SB, Mazzola E, Buckley JM, et al. The role of chemoprevention in modifying the risk of breast cancer in women validation of these criteria is lacking; with atypical breast lesions. Breast Cancer Res Treat. 2012;136(3):627-633. therefore, surgical excision remains the 3. Menes TS, Kerlikowske K, Lange J, et al. Subsequent breast cancer risk standard of care for ADH found on CNB. following diagnosis of atypical ductal hyperplasia on needle biopsy. If safety of omitting surgical excision JAMA Oncol. 2017;3(1):36-41. for the low-risk subgroup of ADH could 4. Chuba PJ, Hamre MR, Yap J, et al. Bilateral risk for subsequent breast cancer after lobular carcinoma-in-situ: Analysis of surveillance, be established, more than 3,000 women epidemiology, and end results data. J Clin Oncol. 2005;23(24):5534-5541. each year might be spared an operation 5. King TA, Pilewskie M, Muhsen S, et al. Lobular carcinoma in situ: A from which they derive no value. As 29-year longitudinal experience evaluating clinicopathologic features compelling as this goal is, it would be and breast cancer risk. J Clin Oncol. 2015;33(33):3945-3952. 60 | premature to omit surgical excision for 6. Mooney KL, Bassett LW, Apple SK. Upgrade rates of high-risk breast lesions diagnosed on core needle biopsy: A single institution ADH on CNB outside of a clinical trial. experience and literature review. Mod Pathol. 2016;29(12):1471-1484. 7. Sen LQ, Berg WA, Hooley RJ, Carter GJ, Desouki MM, Sumkin JH. Core breast biopsies showing lobular carcinoma in situ should be Conclusion excised and surveillance is reasonable for atypical lobular hyperplasia. Both lobular neoplasia and ADH confer a AJR Am J Roentgenol. 2016;207(5):1132-1145. 8. Nakhlis F, Gilmore L, Gelman R, et al. Incidence of adjacent synchronous long-term increased risk of breast cancer, invasive carcinoma and/or ductal carcinoma in-situ in patients with and should trigger discussion of risk- lobular neoplasia: Results from a prospective multi-institutional registry reduction and surveillance strategies. (TBCRC 020). AJR Am J Roentgenol. 2016;23(3):722-728. Surgical excision is standard of care for 9. Khoury T, Kumar PR, Li Z, et al. Lobular neoplasia detected in MRI- ADH identified on core biopsy, though guided core biopsy carries a high risk for upgrade: A study of 63 cases from four different institutions. Mod Pathol. 2016;29(1):25-33. current research efforts are focused on 10. Wazir U, Wazir A, Wells C, Mokbel K. Pleomorphic lobular carcinoma identifying a subgroup where excision in situ: Current evidence and a systematic review. Oncol Lett. might safely be omitted. Surgical excision is 2016;12(6):4863-4868. also recommended for “non-classic” LCIS, 11. Flanagan MR, Rendi MH, Calhoun KE, Anderson BO, Javid SH. such as pleomorphic LCIS and LCIS with Pleomorphic lobular carcinoma in situ: Radiologic-pathologic features and clinical management. Ann Surg Oncol. 2015;22(13):4263-4269. comedo-necrosis, and for LCIS found on 12. Bahl M, Barzilay R, Yedidia AB, Locascio NJ, Yu L, Lehman CD. High- core biopsy of enhancing lesions on MRI. risk breast lesions: A machine learning model to predict pathologic For ALH, growing evidence supports upgrade and reduce unnecessary surgical excision. Radiology. omission of surgical excision when there is October 17, 2017 [Epub ahead of print]. no mass lesion, no accompanying ADH, and 13. Nguyen CV, Albarracin CT, Whitman GJ, Lopez A, Sneige N. Atypical ductal hyperplasia in directional vacuum-assisted biopsy of breast biopsy was performed by large core vacuum- microcalcifications: Considerations for surgical excision. Ann Surg assisted biopsy with excellent sampling and Oncol. 2011;18(3):752-761. concordance with the target image. For 14. Pena A, Shah SS, Fazzio RT, et al. Multivariate model to identify LCIS, surgical excision should be considered, women at low risk of cancer upgrade after a core needle biopsy taking into account the clinical context diagnosis of atypical ductal hyperplasia. Breast Cancer Res Treat. 2017;164(2):295-304. and patient goals (see Table 1, this page). ♦

V103 No 2 BULLETIN American College of Surgeons YOUR ACS BENEFITS

Underused resources every ACS member should know about

by Connie Bura

his month’s column features three different WEBINAR PRESENTATION TOPICS sets of resources T • The Art of Negotiation developed specifically for members of the American • Basic Principles of Coding and Reimbursement for Young Surgeons College of Surgeons (ACS). Over the past year, the Resident • Becoming Your Own Boss: Tips for Starting Your Own Surgical Practice and Associate Society (RAS-ACS) • Being a Leader Within Your Hospital and on Your Medical Staff produced a comprehensive webinar series for young surgeons. More • Clinical Documentation Improvement than 100 members participated • Contract Negotiations: Advice and Pitfalls to Avoid in each live webinar, but did you know that the archived • Cultivating the Next Generation of Surgeon-Scientists | 61 versions can be viewed for free? • Disability Insurance from the ACS Insurance Program In addition, the members of the ACS Board of Governors (B/G), • Domestic Volunteerism: Options for Young Surgeons Who Want to Help who represent members of the • Drug Shortages: The Problem, Possible Causes, and Future Directions College in their state, region, or specialty, work to create useful • Functional Ergonomics for Surgeons: Protect Your Neck and Your Career tools for surgeons. In the past • Global Surgery for the Young Surgeon year, the B/G has released a series of training presentations • Marketing for the Young Surgeon: directed at residents and others. Why Understanding Marketing Is Important The College also offers a variety • Mindfulness and Work-Life Balance for the Busy Surgeon of discount programs that benefit our members. These affinity • Patients in the Know: Impact on Recovery programs include partnerships • Preparing a Top-Notch Fellowship Application that the ACS has established to provide special rates and services • Principles of Leadership for the Young Surgeon to our members. These programs • Protect Your Online Reputation may not be something most members associate with the • Safety, Wellness, and Logistics for the Pregnant Surgeon ACS, but a brief review of what’s • Seeking Mentorship and Ascending the Academic/Private Practice Ladder available may spark your interest. • Transcare for the Transgender Patient in the Surgeon’s Office • Understanding the Difference Between Leadership and Power Webinars for young surgeons The RAS-ACS webinar series is targeted at young surgeons who are starting their practice in

FEB 2018 BULLETIN American College of Surgeons YOUR ACS BENEFITS

private or academic surgical it’s best to draft that letter while In addition, the B/G has medicine. These webinars, the student’s performance is developed four teaching which run up to 60 minutes, fresh in your memory. To help modules for use by faculty that take a deep dive into career ensure that you cover all of the address key topics relevant to path choices and strategies, salient points, the B/G created training residents and others. best practices for navigating the this standardized letter, which Each presentation can be career ladder, and managing covers all of the key points downloaded free of charge personal life and wellness. They you’d like to address when from the B/G Resources web provide young surgeons with recommending a medical student page at facs.org/about-acs/ new strategies and tools on for residency. It is recommended governance/board-of-governors/ relevant topics, are presented that you download the letter resources. Modules available at live by subject matter experts, template so that you have present include the following: and are accessible to ACS access to it when needed. 62 | members free of charge. Enjoy The B/G also has developed • Clinical Teaching: The interaction with the presenter an Onboarding Checklist for Teachable Moment—a 21-slide in a live format or view the Surgeons, available at facs.org/ PowerPoint presentation webinar later when your onboardingsurgicalchecklist, which schedule permits. These brief, offers action items for • Giving Constructive yet informative, educational consideration by a new surgeon, Feedback—a 41-slide programs are accessible for one and the surgeon, group, or PowerPoint presentation year after the event at facs.org/ hospital hiring a surgeon. member-services/ras/webinars. The list is divided into items • Intraoperative Visit the RAS-ACS regarding preparation for Teaching—a 33-slide website to view and sign up practice life and items related PowerPoint presentation for upcoming webinars. to an employment contract, which are intended to serve as • Teaching Millennials—a 22-slide guidelines for discussion—not PowerPoint presentation B/G resources for members mandatory requirements. Some The B/G released several material in the “Preparation new tools. One example for practice life” section may ACS affinity programs is a standardized letter of be included in a contract. Many members don’t realize recommendation for medical Although many surgeons that the ACS offers a variety of students available at facs.org/ have had input, the list is discounted affinity programs to about-acs/governance/board-of- not exhaustive and will be its members. The ACS discount governors/resources. It’s never too updated as necessary. The programs include exclusive early to begin thinking about College encourages you to members-only discounts and those medical students who download the checklist and benefits on rental cars from may be asking you to write a keep it handy for when you are AVIS, medical liability insurance letter of recommendation for starting or joining a practice coverage from The Doctors their residency application, and or hiring a new surgeon. Company, an ACS credit card

V103 No 2 BULLETIN American College of Surgeons YOUR ACS BENEFITS

AIG Private Client Group property and casualty insurance products are designed to help protect and minimize threats to the personal assets and safety of policyholders.

and personal checking account • Yacht insurance • Conflict resolution from Bank of America, free admission to museums across AIG Private Client Group • Top 10 things to avoid in your the country, discounted titles can help safeguard both your first years of practice from the publisher Springer, assets and your way of life with and access to informed consent a complimentary insurance The ACS Division of Member documents for a range of review to help identify gaps Services anticipates that as surgical procedures. In addition in your current coverage. you review these benefits, you to these benefits, we offer a Visit the AIG website for will find something that is full suite of ACS Insurance ACS members at www-207. useful to you in your practice Program products. The newest aigprivateclient.com/index. or personal life. For details additions to our affinity php?cmpid=DMC-Surgeons to sign about any of these items, program offerings are American up for ACS member discounts. contact Connie Bura, Associate International Group (AID) Director, Division of Member | 63 property and casualty insurance Services, at [email protected]. ♦ and Collette Travel. Visit facs. What’s to come org/member-services/benefits/ All members are encouraged to discount for more information. review and take advantage of AIG Private Client Group these resources. Throughout property and casualty insurance the year, this column will products are designed to help offer more information about protect and minimize threats ACS resources, including a to the personal assets and series of brief essays developed safety of policyholders. With by the B/G that address an integrated approach toward the following topics: insurance, AIG strives to reduce the cost and magnitude • How to obtain work/life balance of risk for policyholders. during the early practice years AIG Private Client Group offers insurance solutions for • Flash points in contract a variety of coverage needs, negotiation: Potential areas of including the following: contention

• Homeowners insurance • Best advice on strategic resource negotiation when starting a • Personal excess liability surgical practice

• Auto insurance • Coding pearls

• Private collections insurance • How to build referrals

FEB 2018 BULLETIN American College of Surgeons A LOOK AT THE JOINT COMMISSION

Joint Commission publishes 2018 National Patient Safety Goals

by Carlos A. Pellegrini, MD, FACS, FRCSI(Hon), FRCS(Hon), FRCSEd(Hon)

he Joint Commission’s Surgery (OBS) Accreditation [The NPSGs] were developed, 2018 National Patient programs are listed below and have been updated TSafety Goals (NPSGs) are and feature language from in effect and available on The the simplified versions of the with, input from the Patient Joint Commission’s website. NPSGs. It is important to note Safety Advisory Group, which These standards are simple, that some NPSGs are applicable is composed of nurses, actionable, and applicable to the only to the hospital program, work that surgeons perform, not to the OBS program. physicians, pharmacists, especially the Universal risk managers, clinical Protocol (UP) for Preventing UP for Preventing Wrong Wrong Site, Wrong Procedure, Site, Wrong Procedure, engineers, and other health Wrong Person Surgery. Wrong Person Surgery care professionals. The NPSGs were established in 2002 to help accredited • UP.01.01.01: Make sure that the 64 | organizations address specific correct operation is done on the areas of concern with respect to correct patient and at the correct patient safety issues. The first set place on the patient’s body. of NPSGs took effect in January 2003. They were developed • UP.01.02.01: Mark the correct and have been updated with place on the patient’s body where input from the Patient Safety the operation is to be done. Advisory Group, which is composed of nurses, physicians, • UP.01.03.01: Pause before the pharmacists, risk managers, operation to make sure that a clinical engineers, and other mistake is not being made. health care professionals. The 2018 NPSGs outlines NPSG 1: Improve the accuracy goals for the following of patient identification programs: ambulatory health care, behavioral health care, • NPSG.01.01.01: Use at least two critical access hospital, home ways to identify patients. For care, hospital, laboratory example, use the patient’s name services, nursing care center, and date of birth. This step is and office-based surgery. done to ensure that each patient gets the correct medicine and treatment. NPSGs for hospital and office-based surgery • NPSG.01.03.01: Make sure that The 2018 NPSGs applicable the correct patient gets the to The Joint Commission’s correct blood when a blood Hospital and Office-Based transfusion is performed.

V103 No 2 BULLETIN American College of Surgeons A LOOK AT THE JOINT COMMISSION

The 2018 NPSGs outlines goals for the following programs: ambulatory health care, behavioral health care, critical access hospital, home care, hospital, laboratory services, nursing care center, and office-based surgery.

NPSG 2: Improve the alarms on medical equipment to try to commit suicide effectiveness of communication are heard and responded to on (hospital program only). among caregivers time (hospital program only).

• NPSG.02.03.01: Get NPSG 7: Reduce the risk of health For more information important test results to the care-associated infections Questions about the 2018 right staff person on time NPSGs should be directed (hospital program only). • NPSG.07.01.01: Use the hand- to The Joint Commission’s cleaning guidelines from the Standards Interpretation NPSG 3: Improve the safety Centers for Disease Control and Group at 630-792-5900 or by of using medications Prevention or the World Health using the Standards Online Organization. Set goals for Question Form available at • NPSG.03.04.01: Before a improving hand cleaning. Use the http://web.jointcommission. procedure, label medicines that goals to improve hand cleaning. org/sigsubmission/ are not labeled (for example, sigquestionform.aspx. | 65 medicines in syringes, cups, and • NPSG.07.03.01: Use proven The full chapter of 2018 basins). Do this in the area where guidelines to prevent infections NPSGs for the Hospital medicines and supplies are set up. that are difficult to treat Accreditation program (hospital program only). is available at www. • NPSG.03.05.01: Take extra care jointcommission.org/assets/1/6/ with patients who take blood • NPSG.07.04.01: Use proven NPSG_Chapter_HAP_Jan2018.pdf. thinners (hospital program only). guidelines to prevent infection To view the NPSGs for of the blood from central lines all programs, visit www. • NPSG.03.06.01: Record and pass (hospital program only). jointcommission.org/standards_ along correct information about information/npsgs.aspx. ♦ a patient’s medicines. Find out • NPSG.07.05.01: Use proven what medicines the patient is guidelines to prevent infection taking. Compare those medicines after the operation. Disclaimer with new medicines given to the The thoughts and opinions patient. Make sure the patient • NPSG.07.06.01: Use proven expressed in this column are knows which medicines to guidelines to prevent solely those of Dr. Pellegrini and take at home. Tell the patient infections of the urinary tract do not necessarily reflect those it is important to bring an up- that are caused by catheters of The Joint Commission or the to-date list of medicines every (hospital program only). American College of Surgeons. time they visit a doctor. NPSG 15: The organization NPSG 6: Reduce the harm associated identifies safety risks inherent with clinical alarm systems in its patient population

• NPSG.06.01.01: Make • NPSG.15.01.01: Find out improvements to ensure that which patients are most likely

FEB 2018 BULLETIN American College of Surgeons NTDB DATA POINTS

2017 Pediatric Annual Report: ICD-10

by Richard J. Fantus, MD, FACS

he 2017 Pediatric Report TABLE 1. of the National Trauma ® ® DIFFERENCES BETWEEN ICD-9-CM TData Bank (NTDB ) is an AND ICD-10-CM CODE SETS updated analysis of the largest aggregation of U.S trauma ICD-9-CM ICD-10-CM registry data ever assembled. In total, the NTDB now contains 3 to 5 characters in length 3 to 7 characters in length more than 8 million records. Approximately 68,000 The 2017 Pediatric Report is Approximately 13,000 codes based on 156,244 admission current codes year records for 2016 submitted 66 | by 762 facilities. There are 27 First character may be Character 1 is alpha; characters alpha (E or V) or numeric; 2 and 3 are numeric; characters Level I or Level II pediatric- characters 2–5 are numeric 4–7 are alpha or numeric only centers; 20 are standalone Level I pediatric centers, and Limited space for new codes New codes can be added seven are standalone Level II pediatric centers. The NTDB Limited code detail Specific code detail classifies pediatric patients in this report as patients who are No laterality Includes laterality younger than 20 years of age.

Use of ICD-10 in report development The International Classification of Diseases (ICD), owned and published by the World Health Organization, is the world-standard diagnostic tool for health management, epidemiology, and clinical purposes. ICD is used to monitor incidence and prevalence of diseases and other health care problems.* In 2009, the U.S.

*World Health Organization. Classifications. Available at: www.who.int/classifications/icd/ en/. Accessed December 27, 2017.

V103 No 2 BULLETIN American College of Surgeons NTDB DATA POINTS

Many dedicated individuals of the ACS COT, including the Pediatric Surgery Subspecialty group, along with dedicated individuals who provide care to pediatric patients at trauma centers across the country, contributed to the early development of the NTDB and its rapid growth in recent years.

Department of Health and repository for trauma center Annual Report are available on Human Services published registry data. The purpose the ACS website as a PDF file a regulation requiring U.S. of this report is to inform at facs.org/ntdb. In addition, the providers to transition from the medical community, the website contains information on the ninth edition of the public, and decision makers how to obtain NTDB data for classification system (ICD-9) about a variety of issues that more detailed study. If you are to ICD-10, which is what the characterize the current state of interested in submitting your rest of the world was using. care for injured pediatric patients trauma center’s data, contact ICD-10 has several advantages in our nation. It has implications Melanie L. Neal, Manager, over its predecessor. Some for many areas, including NTDB, at [email protected]. ♦ trauma-related highlights epidemiology, injury control, include expanded injury codes, research, education, acute | 67 a combination of diagnosis/ care, and resource allocation. Acknowledgment symptom codes to reduce the Many dedicated individuals Statistical support for this article number of codes necessary to of the ACS COT, including the was provided by Ryan Murphy, describe a condition, and two Pediatric Surgery Subspecialty Data Analyst, NTDB. additional characters added, group, along with dedicated along with subclassifications individuals who provide care to allow laterality and greater to pediatric patients at trauma specificity in code assignment. centers across the country, This report uses admission contributed to the early year 2016 records, and development of the NTDB and 95 percent of those containing its rapid growth in recent years. valid ICD codes are reported Building on these achievements, with ICD-10 nomenclature the goals in the coming years (see Table 1, page 66). include improving data quality, updating analytic methods, and enabling more useful ACS COT goals in inter-hospital comparisons. publishing the report These efforts will be reflected The mission of the American in future NTDB reports to College of Surgeons (ACS) participating hospitals, as well Committee on Trauma (COT) as in annual pediatric reports. is to develop and implement Throughout the year, we meaningful programs for trauma will be highlighting NTDB data care. In keeping with this through brief monthly reports mission, the NTDB is committed in the Bulletin. All previous to being the principal national years of the NTDB Pediatric

FEB 2018 BULLETIN American College of Surgeons Dear sir or madam,LETTERS @  Letters to the Editor  @ To whom it may concern,

Editor’s note: The following develop programs like Stop the comments were received Hemorrhage control training Bleed® and bleedingcontrol.org to regarding recent articles should be mandatory for address potentially survivable published in the Bulletin. health care professionals deaths. The goal: teach After every terrible tragedy, we bystanders to identify and treat Letters should be sent with see bystanders, news outlets, life-threatening bleeding with the writer’s name, address, and social media forums direct pressure, tourniquets, e-mail address, and daytime discussing the importance of and pressure dressings.† telephone number via e-mail hemorrhage control. However, We expect and encourage to [email protected], or interest in these lifesaving skills the bystander to seek these via mail to Diane Schneidman, waxes and wanes with active training opportunities and Editor-in-Chief, Bulletin, American shooter or terrorist incidents. In become certified in bleeding College of Surgeons, 633 N. Saint 2016, the National Academies control; however, there is Clair St., Chicago, IL 60611. of Science, Engineering, little expectation that medical 68 | and Medicine published the professionals learn these skills. Letters may be edited for length report, A National Trauma Care Bleeding control is not mandatory or clarity. Permission to publish System: Integrating Military training in the majority of letters is assumed unless the and Civilian Trauma Systems to medical schools, although it’s author indicates otherwise. Achieve Zero Preventable Deaths not uncommon for students After Injury, which stated to undergo cardiopulmonary that approximately 30,000 resuscitation (CPR) training potentially survivable deaths before matriculation. Nor occur in the U.S. each year.* is bleeding control training The Hartford Consensus offered in many medical schools. gave us a foundation to Hospitals do not require bleeding eliminate preventable death. control training but often require The collaboration between CPR certification for physicians the American College of applying for privileges. Surgeons and the Department of A Stop the Bleed course Homeland Security has helped can be completed in as little as two hours. Many injuries that *National Academies of Sciences, cause life-threatening bleeding Engineering, and Medicine. A National are immediately treatable, Trauma Care System: Integrating Military and Civilian Trauma Systems to Achieve Zero and this care will saves lives. Preventable Deaths After Injury. Washington, Compare this with the results DC: The National Academies Press; 2016. from administering CPR for †Jacobs LM. Out of unspeakable tragedy comes progress in bleeding control. cardiac arrest, where underlying Bull Am Coll Surg. 2017;102(6):11-16. disease is common—even with ‡Institute of Medicine. Strategies the best prehospital treatment to Improve Cardiac Arrest Survival: A Time to Act. Washington, DC: The and return of spontaneous National Academies Press; 2015. circulation, outcomes are poor.‡

V103 No 2 BULLETIN American College of Surgeons Dear sir or madam, LETTERS @     @ To whom it may concern,

Why does the health care death from bleeding. These Why does the health care system expect bystanders to opportunities can also bring take bleeding control courses, forward students who can system expect bystanders yet have no expectations of the eventually become instructors to take bleeding control people who comprise the same and teach hemorrhage health care system? For society control to the community. courses, yet have no to understand the importance of In turn, we will help create expectations of the people hemorrhage control, all health community outreach projects who comprise the same health care professionals should be that will benefit bystanders certified in a bleeding control and medical leaders alike. care system? For society to course. A health care professional We, as health care understand the importance is anyone who participates professionals, cannot expect directly in patient care. bystanders to understand the of hemorrhage control, all The solution starts by importance of bleeding control health care professionals mandating bleeding control and trauma care if health care | 69 training for employment as professionals continue to ignore should be certified in a a health care professional at the importance of these skills. bleeding control course. a hospital or clinic. Physician To truly address the impact of credentialing should require trauma and accidents on our mandatory training that population, we must start with allows the physician to identify health care professionals. and treat life-threatening Andrew D. Fisher, MPAS, PA-C, MS-2 hemorrhage. Additional courses Texas A&M College of Medicine or instruction are available to Temple, TX identify and treat the other two leading causes of preventable death—tension pneumothorax and airway obstruction. The next logical step is the requirement that bleeding control be taught early in medical school education— possibly the first week of medical school and with the assistance of emergency medical services and other emergency health care professionals. These efforts will give medical students a real-life skill and help them understand the importance of preventable

FEB 2018 BULLETIN American College of Surgeons NEWS

TQIP annual meeting shares best practices, advances in trauma care

by Tony Peregrin

The 2017 Trauma Quality Dr. Jacobs, chair of the Hartford Improvement Program (TQIP) Empowering the public Consensus Joint Committee Annual Scientific Meeting and to Stop the Bleed to Enhance Survivability from Training, November 11−13 Citing a Texas State University Active Shooter and Intentional in Chicago, IL, drew nearly and U.S. Federal Bureau of Mass Casualty Events, and 1,650 attendees—a 15 percent Investigation (FBI) study, a Regent of the College. increase from 2016 and the Dr. Jacobs outlined active shooter “The mission is to keep highest number to date— incidents with the highest casualty the blood in the body any including trauma medical counts between 2000 and 2013, way that you can,” he said. directors, program managers, including Cinemark Century 16 Dr. Jacobs also described how coordinators, and registrars. Theater, Aurora, CO (12 killed and the efforts of the U.S. military’s Highlights of the eighth 58 wounded); Virginia Polytech Tactical Combat Casualty Care annual TQIP meeting include Institute, Blacksburg (32 killed and (TCCC) program led to a renewed 70 | a keynote presentation titled 17 wounded); and Sandy Hook focus on prehospital tourniquet Increasing Survival from Elementary School, Newtown, use. Before TCCC guidelines Active Shooter and All Severe CT (27 killed and 2 wounded). were introduced, military Hemorrhagic Events by “These children did not go medics were instructed to use a Lenworth M. Jacobs, Jr., MD, to school to be shot, they went tourniquet only as a final measure MPH, FACS, vice-president of to school to learn,” Dr. Jacobs to stem extremity hemorrhage. academic affairs and chief said, referring to the Sandy Hook After widespread implementation academic officer at Hartford event, which proved to be the of TCCC tourniquet Hospital, Hartford, CT; tipping point for the ACS and recommendations, deaths from updates and progress reports other organizations to begin extremity hemorrhage decreased on TQIP and Committee on considering ways to improve significantly, Dr. Jacobs said, Trauma (COT) initiatives; an survival from these situations. citing a comprehensive study of overview of American College “If you can stay alive for 10 4,596 U.S. combat fatalities from of Surgeons (ACS) military to 25 minutes, you are probably 2001 to 2011, which found that the partnerships specifically going to be okay. The duration of incidence of preventable deaths related to National Academies the Virginia Tech event was eight from extremity hemorrhage had of Science, Engineering, to nine minutes, with 174 rounds decreased to 2.6 percent. “This and Medicine (NASEM) shot. The event at Fort Hood data is very powerful information report activities; a session lasted 10 minutes, with 214 rounds to take to the decision makers summarizing teamwork shot. In Las Vegas, more than of the U.S.,” he said. essentials for the trauma team; 1,000 rounds were shot, and it was After the Joint Committee and a presentation from trauma over in 10 minutes. Civilians had to Create a National Policy to survivor Noah Galloway, who to make life-or-death decisions, Enhance Survivability from lost an arm and a leg in an and therefore, they should be Intentional Mass Casualty improvised explosive device engaged in training and decision and Active Shooter Events attack during Operation Iraqi making. Our mantra is to inform, was convened by the ACS in Freedom in December 2005. educate, and empower,” said April 2013 in collaboration

V103 No 2 BULLETIN American College of Surgeons NEWS

Dr. Nathens Conference attendees with representatives from been trained in Stop the Bleed Dr. Nathens also described the medical community, the principles, Dr. Jacobs said. the QuintilesIMS (now called National Security Council, the IQVIA) partnership with the U.S. military, the Federal Bureau ACS, which provides a “common of Investigation, and others, the TQIP update data platform that will provide committee developed a set of “Inspiring quality: Better a shared data infrastructure recommendations collectively standards, better outcomes— across ACS Quality Programs known as the Hartford but how do we it?” said Avery and new and enhanced business Consensus. The primary aim Nathens, MD, PhD, FACS, FRCSC, tools,” he said, including tools of the Hartford Consensus is in his opening remarks. “We for advanced data validation to prevent anyone from dying do this through the four pillars business intelligence. He noted from uncontrolled bleeding. of quality: setting standards, the favorable reviews from initial A national Hartford building the right infrastructure, pilot testers, including comments Consensus survey assessed using robust data, and verifying describing how easy the reports | 71 the general public’s interest in that everyone is consistent with were to decipher, how the data acting as immediate responders, those standards.” Dr. Nathens displayed seamlessly via Excel with 92 percent of respondents is surgeon-in-chief, department spreadsheets, and how users were indicating they would be very of surgery, medical director, able to navigate quickly through likely or somewhat likely trauma, Sunnybrook Health the validation summary report, to try to control bleeding in Sciences Centre, Toronto, ON; allowing them to identify and someone they did not know. and Medical Director, ACS fix errors. He emphasized that The survey results, according to Trauma Quality Programs. local registries would remain the Dr. Jacobs, suggested a need for The College’s Quality same, but other factors might strategies to educate laypeople Programs touch 2,800 hospitals change, including program in hemorrhage control, which around the world, according to nomenclature and definitions, led to the launch of the Stop Dr. Nathens, and lead to greater as well as corrective actions the Bleed® campaign in access to surgical care, fewer and resolution timeframes. October 2015. Bleeding control complications, and improved Dr. Nathens also outlined kits, a key component of this outcomes in the areas of trauma, plans for revising the Resources for initiative, contain pressure cancer, breast care, bariatric Optimal Care of the Injured Patient bandages, hemostatic dressings, surgery, and overall surgical care. manual. “We are focused on tourniquets, and gloves. “We He highlighted several recent revising standards in the ‘orange patterned the kits off of the initiatives that support the work book,’ and we put forward specific U.S. military. They have tested of these programs, including goals. First, we are going to drop and deployed this equipment the publication of the Optimal criteria that are burdensome and with positive results,” he said. Resources for Surgical Quality and that have limited patient benefit. As of November 2017, Safety manual (the red book), We are also going to incorporate more than 8,000 instructors which describes key concepts in clarifications and prioritize and more than 100,000 quality, safety, and reliability to changes based on evidence and participants worldwide have ensure patient-centered care. expert opinion. Perhaps most

FEB 2018 BULLETIN American College of Surgeons NEWS

From left: Drs. Nathens, Bulger, and Stewart

importantly, we are going to be was released in November 10th edition of the Advanced a bit broader in terms of input. In 2017 and provides health care Trauma Life Support® (ATLS®) the past, it was a small committee, professionals with evidence-based program, which he called “the but now we have [representatives] recommendations regarding most exciting update since its from PIPS [the ACS COT the care of the trauma patient. inception.” Due for release in Performance Improvement A new best practices guideline the spring, the new edition of and Patient Safety Program], on imaging is due in early 2018, the ATLS course will feature TQIP, VRC [ACS COT’s Trauma according to Dr. Nathens. Future updated core content, interactive Center Verification, Review, best practices guidelines will discussions, and structural and Consultation], and STN cover nonaccidental trauma such changes to the skills stations. [the Society of Trauma Nurses] as child abuse and elder abuse. A push to complete the providing many perspectives, In addition, Dr. Nathens national trauma system, a with changes that are hopefully outlined key recommendations in component of the NASEM report, 72 | more meaningful in terms of the NASEM report, particularly is another priority for the COT, improving patient care.” Recommendation 5, which especially considering that at Another important component calls for military and civilian least one-third of Americans of Dr. Nathens’ TQIP update trauma systems to collect and today reside in an area without focused on the ACS TQIP share common data spanning a complete trauma system. Benchmark Report released in the continuum of care. “Now is the time to fill in the the fall of 2017, which is based “Is there life after discharge? patchwork quilt of the national on admissions from 2016 and An estimated 50 percent suffer trauma system,” Dr. Stewart said. the first quarter of 2017 from from chronic pain, 40 percent “We must implement a National 466 TQIP centers. “This is the suffer from anxiety or depression, Trauma Action Plan now, and first year where we focused on and 25 percent have post- quite frankly, we need your AIS [abbreviated injury scale] traumatic stress disorder. We leadership [to do this],” he said. 2005, which is a shift from AIS have to change our notion He described the pillars of 1998 and affects adult, Level of trauma beyond ‘alive or a modern trauma system— III, and collaborative reports,” dead.’ Traumatic injury is a prevention, acute care, Dr. Nathens said. He noted complex, chronic disease…and rehabilitation, a framework for the 2017 report features an we have to figure out what we disaster preparedness—and he expanded section on orthopaedic can do in the acute phase of noted that these pillars will be trauma care, with a greater care that will improve these fully realized through teamwork focus on tibia shaft fractures. outcomes,” Dr. Nathens said. and the leadership provided by the Dr. Nathens also highlighted incoming Chair of the ACS COT, TQIP best practice guidelines Eileen Metzger Bulger, MD, FACS. for managing different patient COT update In addition, Dr. Stewart populations and processes, Ronald M. Stewart, MD, FACS, described the “two contrasting including the recently released Chair of the COT, provided narratives” regarding firearm ACS TQIP Palliative Care Best an overview of key COT injury prevention. In a Practices Guidelines, which initiatives, including the new 32-question survey completed by

V103 No 2 BULLETIN American College of Surgeons NEWS

Dr. Hoyt Conference attendees

U.S. COT members in February rather than plasma, and that from the service, and others 2016, slightly more than half Paul Hawley, MD, FACS(Hon), return to a garrison practice of surgeons surveyed adhere Past-Director of the ACS, has with little trauma exposure. to one narrative that considers been credited with developing Currently, of the 57 military firearms important for safety the U.S. Department of Veterans treatment facilities, only seven and are emblematic of personal Affairs’ health care system. see trauma, and only one is liberty. In contrast, approximately “Vietnam is when we started verified by the ACS Committee 30 percent of surgeons surveyed to really change things, from a on Trauma as a Level I center.” subscribe to the second narrative trauma standpoint, because of the To enhance MHS readiness, that firearms place citizens at risk availability of helicopters,” added Dr. Hoyt and Jonathan for harm and reduce personal Dr. Hoyt. “Patients were now Woodson, MD, FACS, then- liberty. He called for stakeholders transported to where physicians Assistant Secretary of Defense to approach firearm injury could do something,” he said, for Health Affairs, signed a prevention as a public health underscoring the importance of memorandum of understanding | 73 issue and to engage in “consensus rapid evacuation to definitive care. in October 2014 that focused decision making centered around After describing these on education and training for doing the right thing for the historic accomplishments in military surgeons, quality patient and our citizens.” trauma care, Dr. Hoyt focused initiatives, systems-based practice on the future of civilian and related to the military trauma military surgical collaboration system, and trauma research. ACS military partnership specifically related to military “We brought together 12 David B. Hoyt, MD, FACS, Executive health system (MHS) readiness. surgeon subject matter experts Director of the College, Citing a study of 86 military- (SMEs) who had seen deployment described the Military Health affiliated surgeons conducted by and had experience in surgical Service Strategic Partnership C. William Schwab, MD, FACS, education,” Dr. Hoyt said, American College of Surgeons FRCS, Dr. Hoyt noted that more referring to steps taken to execute (MHSSPACS), which launched than 50 percent had two years the education and training in December 2014, as the most or less of independent surgical component of the agreement. recent example of a long tradition practice for their first deployment. The SMEs, representing the of the military and civilian Almost 25 percent were stationed Army, Navy, and Air Force, surgeons working together without another general compiled a list of topics based on to improve patient care. As surgeon present, and 60 percent the Joint Trauma System Clinical examples of the contributions found their pre-deployment Practice Guidelines. The list was, of ACS members, Dr. Hoyt military training unhelpful. in turn, distributed to nearly noted that COL Edward D. “And, so, what happens 700 surgeons with deployment Churchill, MD, FACS, Theater when peace breaks out?” asked experience to develop training Commander for Surgery in the Dr. Hoyt, referring to surgeons course and assessment tools. Mediterranean in World War II, who deploy on missions with COL Brian J. Eastridge, MD, challenged military brass to treat little surgical activity. “Many FACS, professor, department of hemorrhagic shock with blood with combat experience separate surgery, division chief, trauma

FEB 2018 BULLETIN American College of Surgeons NEWS

From left: Dr. Jenkins, Mr. Galloway, and Dr. Eastridge

and emergency general surgery, of combat—times of war with stakeholders (both physicians University of Texas Health lengthy periods of peace in and nonphysicians) was designed Science Center, San Antonio, between—is one challenge to to “disseminate, refine, and underscored the importance of maintaining a military trauma implement the NASEM report enhancing prehospital treatment system, according to Dr. Jenkins, recommendations,” he said. of battlefield casualties to as is the lack of a discernable College and COT initiatives based reduce case fatality rates and career path for military trauma on the recommendations of the preventable deaths among U.S. leaders within the Department NASEM report and discussed servicemen and women. “We of Defense (DoD) health care at the conference include the looked at combat deaths that system. Another barrier to development of minimum were occurring before patients developing a joint workforce trauma system standards with even reached the hospital, centers on the fact “some the goal of creating a national and 25 percent were found to military occupations do not trauma system and a partnership 74 | likely have a survivable injury. have a civilian counterpart, with the National Association A large majority, about 90 and often credentialing and of State Emergency Medical percent, died from hemorrhage,” licensing are not transferable to Services Officials (also known Dr. Eastridge said, citing a the civilian setting,” he said. as NASEMSO) to develop a published study that examined One solution to these joint policy statement linking 4,596 battlefield fatalities between workforce-related challenges EMS and hospital data. October 2001 and June 2011. involves revamping entry-level “Now that TCCC is broken training for the trauma workforce up into phases of care, we’ve so that it is more uniform Essentials of teamwork got better techniques and through the development of for the trauma team technology for hemorrhage a standard curriculum and “There is a prevalent theory control,” he said. TCCC phases assessment to measure skills and that says safety is achieved of care include: (1) care under abilities. Another solution, noted by doing the same thing, the fire, (2) tactical field care, and Dr. Jenkins, is to standardize same way, every time, and that (3) tactical evacuation care. data collection, particularly safety can best be maintained “While both the military in the prehospital setting, by by limiting variability,” said and civilian sector have a high incorporating the DoD Trauma Andrew Grose, MD, assistant level of quality of care, they Registry and the National professor of orthopaedic surgery, are not effectively integrated,” Trauma Data Bank, from the Westchester Medical Center, said Donald Jenkins, MD, FACS, point of injury to rehabilitation. Hawthorne, NY, and associate professor of surgery, vice-chair, The session concluded with editor, Patient Safety in Surgery. department of surgery, University a report from Dr. Hoyt, who “But in the clinical environment, of Texas Health Science Center, provided an update on the everything is rapidly changing San Antonio, noting the NASEM Achieving Zero Preventable and evolving. There is no such report’s call to form a sustainable Deaths Conference that took thing as a routine, uneventful military/civilian workforce place in April in Bethesda, MD. minute, hour, or day.” He noted partnership. The cyclical nature The conference, attended by 169 that threat management and

V103 No 2 BULLETIN American College of Surgeons NEWS

Mr. Caulk (left) and Dr. Grose Mr. Galloway task adaptation skills—which are work,” said Mr. Caulk. The on the 20th season of Dancing with rooted in both technical acumen keys to bolstering team buy-in the Stars in 2015. “People always and communication-based include exhibiting interpersonal ask me, ‘What is the one thing competencies—are essential for skills; supporting participation that turned it around?’ Life is not achieving acceptable outcomes. by each team member; a movie—there isn’t one thing “We do everything we can to asking open-ended questions that happens and everything reduce variability in the airline beyond the yes/no format; is fine,” he said. Mr. Galloway industry,” added co-presenter encouraging team briefings noted that his three children Peter Caulk, a health care crew (setting goals and concerns); were his chief inspiration for resource management expert and standardizing the process. overcoming his emotional and a former instructor for the Checklists only work if they and physical challenges. U.S. Navy’s elite fighter weapons are used 100 percent of the time, Mr. Galloway eventually quit school, also known as Top Gun. are interactive, developed by the smoking and drinking, resumed “The impact of doing these users, easy to use, and can be his fitness regimen, and became | 75 things right is tremendous. In shortened for emergencies when the first veteran and amputee health care there is a certain appropriate, Dr. Grose added. to be featured on the cover of pride if you operate self-deprived Men’s Health magazine as the of sleep, but not in aviation,” “Ultimate Men’s Health Guy.” Mr. Caulk said, citing a study Trauma survivor: Mr. Galloway urged health published in the British Medical Noah Galloway care providers to guard against Journal in 2000 that examined During his second deployment burnout and to make self- 31,033 pilots and surgeons and in 2005, Noah Galloway was care a priority. “Make sure to their attitudes regarding error severely injured after a roadside take care of yourselves. We and teamwork in aviation and bomb exploded while the U.S. need you at your best, because medicine. Of the pilots who Army soldier was driving along a you are saving our lives.” responded to the study’s survey, remote road in southwest Bagdad. The ninth annual TQIP 74 percent answered “yes” when The bomb resulted in the loss of Scientific meeting and Training asked if fatigue has a negative Mr. Galloway’s left arm below the will take place November effect on performance, while elbow and his left leg above the 16–18, 2018, at the Anaheim 30 percent of surgeons, nurses, knee. He woke up on Christmas Convention Center, CA. ♦ and residents responded “yes” to Day at Walter Reed Hospital. the same query, Mr. Caulk said. A period of deep depression Checklists are tools that help set in. “I drank all the time and Acknowledgment ensure safety and reduce errors wasn’t taking care of myself. I The photos in this article in both aviation and medicine, was always into fitness, and I let were taken by Dr. Stewart. but they only work if they that go. I rushed into a second are tethered to effective team marriage and when that didn’t communication. “You can have work, I realized I was really a checklist, but if the culture struggling,” said Mr. Galloway, doesn’t support it, it doesn’t who would eventually place third

FEB 2018 BULLETIN American College of Surgeons NEWS

Leigh A. Neumayer, MD, MS, FACS, elected Chair of ACS Board of Regents

Dr. Neumayer

Leigh A. Neumayer, MD, MS, FACS, responsible for managing Journal of the American College of Tucson, AZ, is the 2017–2018 the affairs of the College. Surgeons, and Annals of Surgery. Chair of the Board of Regents Dr. Neumayer’s most recent (B/R) of the American College work is focused on the diagnosis of Surgeons (ACS). She was Previous leadership roles and treatment of breast cancer via elected at the Annual Business A Fellow of the ACS since innovative technology and clinical Meeting of Members, October 1994 and a member of the B/R trials. She has led investigations 25, 2017, in San Diego, CA. since 2009, Dr. Neumayer has in hernia repair techniques, A general surgeon, served in many leadership roles breast cancer treatment, surgical Dr. Neumayer is professor and within the organization. She quality and outcomes, and chair, department of surgery, was Chair of the Committee surgical education techniques. 76 | and the Margaret and Fenton on Medical Student Education Dr. Neumayer has mentored Maynard Endowed Chair (2001–2003), Vice-Chair of the students, residents, and colleagues in Breast Cancer Research, Surgical Research Committee in these and other pursuits. University of Arizona (UA) (2015–2016), a Governor for Dr. Neumayer studied College of Medicine, Tucson. the ACS Utah Chapter (2002– biomedical engineering at She also is the interim senior 2008), and Vice-Chair of the Colorado State University, Fort vice-president for UA Health Board of Regents (2016–2017). Collins, before getting her Sciences. Before accepting Dr. Neumayer also was Vice- medical degree from Baylor these positions in Arizona, Chair of the Nominating College of Medicine, Houston, Dr. Neumayer was professor, Committee of the Board of TX. She trained in general surgery department of surgery, Governors (2004–2006) and a at the University of California, San University of Utah Health Board of Governors Executive Francisco, and at the University of Sciences Center, and the Committee Member (2008–2011). Arizona, Tuscon. Dr. Neumayer Jon and Karen Huntsman Nationally, Dr. Neumayer then studied clinical research Presidential Professor, University has served on the board of design and statistical of Utah/Huntsman Cancer directors of the American analysis at the University of Institute, Salt Lake City. Board of Surgery (2005–2011) Michigan, Ann Arbor. In her role as Chair of the and as the President of the Board of Regents, Dr. Neumayer Association of Women Surgeons will work closely with the (1997–1998), the Association for Dr. Schwartz elected Vice-Chair ACS Executive Director David Surgical Education (2001–2002), Marshall Z. Schwartz, MD, B. Hoyt, MD, FACS, and will the Association of Veterans FACS, professor of surgery and chair the Regents’ Finance Administration Surgeons pediatrics, and vice-chairman, and Executive Committees. (2002–2003), and the Society of department of surgery, Drexel The College’s 24-member Clinical Surgery (2012–2014). University College of Medicine, Board of Regents formulates At present, she serves on Philadelphia, PA, was elected policy and is ultimately the editorial boards for the Vice-Chair of the ACS Board

V103 No 2 BULLETIN American College of Surgeons NEWS

Dr. Schwartz of Regents. Dr. Schwartz been a Regent since 2009 (2014–2017). At present, he is also is the emeritus surgeon- and has served on many ACS Chair of the Comprehensive in-chief and director of the Committees. He was Chair of Communications Committee surgery research laboratory the Advisory Council Chairs and a Member of the at St. Christopher’s Hospital (2004–2008), the Advisory Surgical History Group for Children, Philadelphia. Council for Pediatric Surgery Executive Committee. ♦ A Fellow of the College (2004–2008), and the Health since 1982, Dr. Schwartz has Policy and Advocacy Group

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FEB 2018 BULLETIN American College of Surgeons NEWS

by Brian Frankel, Michael Carmody, and Katie Oehmen

The American College of change management, managing electronic health record and Surgeons (ACS) will host the complex and diverse teams, ethics health information technology seventh annual Leadership & in surgical leadership, leading in interoperability; increasing Advocacy Summit May 19–22 times of crisis, mentoring for a funding for trauma systems; at the Renaissance Washington, career in surgical leadership, and enhancing cancer care and DC, Downtown Hotel. The more. In addition, a portion of the accreditation; and addressing summit is a dual meeting offering event will be dedicated to sharing surgical workforce and graduate comprehensive and specialized ACS chapter success stories and medical education issues. ACS sessions that provide volunteer working to identify strategies to staff also will help members leaders and advocates with enhance and strengthen chapters. and attendees navigate the the skills and tools necessary For more information about many additional legislative to be effective in those roles. the Leadership Summit, contact changes that lie ahead. 78 | Registration for the event is Brian Frankel, ACS Manager, The Advocacy Summit will now open at facs.org/summit. International Chapter Services begin after the Leadership and Special Initiatives, at Summit on Sunday, May 20, with [email protected] or 312-202-5361. a dinner and keynote address. Leadership Summit Past speakers have included The Leadership Summit television journalist Chuck provides a venue for members Advocacy Summit Todd, political commentator to network with ACS leaders, The Advocacy Summit provides a Chris Matthews, U.S. Army attend professional development unique opportunity to obtain the Gen. (Retired) Stanley A. sessions, and engage with knowledge and skills necessary McChrystal, author Thomas colleagues to determine new and to become a surgeon advocate. Goetz, and journalists Bob innovative ways to face challenges With several legislative priorities Woodward and George Will. and enhance their leadership for Congress to consider before Sessions planned for the skills. It begins Saturday evening, the 2018 midterm elections, following day will focus on May 19, with a Welcome surgeons are encouraged to the political environment in Reception open to all registrants, travel to Washington to learn Washington, and speakers will followed by a full day of about and participate in this provide updates on important programming on Sunday, May 20. unique political climate. health care policies and issues More than 400 ACS leaders Since last year’s summit, that detract from surgeons’ and members are expected to the Division of Advocacy and ability to provide quality patient participate in the Leadership Health Policy (DAHP) has been care. Attendees will then apply Summit. Topics will focus on focused on an extensive list of this knowledge in face-to-face honing the communication and federal legislative priorities, meetings with their senators and strategic thinking skills necessary including reducing administrative representatives and congressional for effective leadership in and out practice burdens; modifying and staff. This portion of the program of the operating room. Speakers implementing new physician provides an opportunity to will address key topics, including payment reforms; improving demonstrate surgery’s strength

V103 No 2 BULLETIN American College of Surgeons NEWS

The summit is a dual meeting offering comprehensive and specialized sessions that provide volunteer leaders and advocates with the skills and tools necessary to be effective in those roles.

on Capitol Hill regarding issues sponsors various events for annual drawing with a grand of importance to surgeons members and SurgeonsPAC prize valued at $3,000, a political and the surgical patient. contributors. These events luncheon featuring a renowned During this three-day provide contributors with unique guest speaker, and presentation conference, participants can networking opportunities of the 2017 PAC awards. Resident expect to receive comprehensive and advanced educational engagement opportunities will advocacy training and learn how sessions aimed at providing be provided as well. In addition, to use these skills throughout an insider’s perspective on the SurgeonsPAC information the year, not just in Washington. how College members can booth will provide attendees with The Advocacy Summit is a great remain active participants a venue to meet DAHP staff to place to interact and share ideas in the political process. learn more about the College’s with other surgeon advocates; In addition to raising funds advocacy and political efforts. meet face-to-face with key health to elect or re-elect congressional For more information | 79 care policymakers and legislators; candidates who support a pro- about the Advocacy Summit, and, perhaps most importantly, surgeon, pro-patient agenda, contact Michael Carmody, become the constituents their SurgeonsPAC will host a reception ACS Congressional Affairs legislators know and trust to at which PAC contributors Coordinator, at mcarmody@facs. offer advice on surgical issues. will be recognized for their org or 202-672-1511. For more The ACS Professional commitment to the surgical information about SurgeonsPAC Association political action profession. Other SurgeonsPAC- activities, e-mail surgeonspac@ committee (ACSPA-SurgeonsPAC) sponsored events include an facs.org or call 202-672-1520. ♦

Coming next month in JACS and online now

Empowering postsurgical patients to improve opioid disposal: A before-and-after quality improvement study

Jessica M. Hasak, MPH; Carrie L. Roth Bettlach, NP; Katherine B. Santosa, MD; et al found that dissemination of an educational brochure improved disposal of unused opioids after surgery. This low-cost, easily implemented intervention can improve disposal of unused opioids and ultimately decrease the amount of excess opioids circulating in our communities. This article and all other JACS content is available at www.journalacs.org. ♦

FEB 2018 BULLETIN American College of Surgeons NEWS

Disciplinary actions taken in 2017

The Board of Regents of the American College of DEFINITION OF TERMS Surgeons (ACS) took the following disciplinary actions at its February 10, 2017, meeting in Chicago, IL: Following are the disciplinary actions that may be imposed for violations • Ron Samuel Israeli, MD, a urology surgeon from New Jersey, was of the principles of the College: expelled from the College. This action was taken after his license to • Admonition: A written notification, practice medicine in the state of New York was placed on probation warning, or serious rebuke. following a finding that he committed professional misconduct by • Censure: A written judgment condemning practicing medicine with negligence on more than one occasion. the Fellow or Member’s actions as wrong. This is a firm reprimand. The Board of Regents took the following disciplinary actions at its June 9, 2017, meeting in Chicago: • Probation: A punitive action for a stated period of time, during which the Member: (a) loses the rights to hold office and to • A plastic surgeon from Riverside, CA, was censured. The Board participate as a leader in College programs; of Regents took this action following a disciplinary action (b) retains other privileges and obligations from the California Medical Board related to patient care. of membership; (c) will be reconsidered by the Central Judiciary Committee periodically 80 | • Tadge Kanjo, MD, a general surgeon from Utah, was expelled and at the end of the stated term. from the College. This action was taken following disciplinary • Suspension: A severe punitive action for action from the Colorado Medical Board that resulted in a period of time, during which the Fellow the relinquishment of his license to practice medicine in or Member, according to the membership that state after he failed to comply with a board order. status: (a) loses the rights to attend and vote at College meetings, to hold office, and to • An otolaryngologist from Somersworth, NH, was participate as a leader, speaker, or panelist censured by the ACS following disciplinary action in College programs; (b) is subject to the from the New Hampshire Board of Medicine. removal of the Member’s name from the public listing and mailing list of the College; (c) surrenders his or her Fellowship certificate The Board of Regents took the following disciplinary to the College, and no longer explicitly or actions at its October 20, 2017, meeting in San Diego, CA: implicitly claims to be a Fellow of the American College of Surgeons; (d) pays the visitor’s • A general surgeon from Morristown, NJ, was registration fee when attending College admonished. The Board of Regents took this action programs; (e) is not subject to the payment of following a finding that this surgeons’ expert witness annual dues. When the suspension is lifted, testimony was in violation of the ACS Bylaws. the Fellow or Member is returned to full privileges and obligations of Fellowship. • Michael Lee King, MD, a general surgeon from Pueblo, CO, • Expulsion: The certificate of Fellowship was suspended from the College with terms and conditions for and all other indicia of Fellowship or reinstatement. This action was taken following the revocation membership previously issued by the of his license to practice medicine in the State of Colorado. College must be forthwith returned to the College. The surgeon thereafter shall not • Larry David Tice, MD, FACS, a neurosurgeon from Fruita, explicitly or implicitly claim to be a Fellow CO, had his full Fellowship privileges restored following a or Member of the American College of period of probation. That probation followed a state medical Surgeons and may not participate as a leader, speaker, or panelist in College programs. board action related to unprofessional conduct. ♦

V103 No 2 BULLETIN American College of Surgeons NEWS

Making quality stick: Optimal Resources for Surgical Quality and Safety Individual disciplines working together in an increasingly regulated environment

Editor’s note: In July 2017, the care surgery; burn, abdominal safety of the health care services American College of Surgeons transplant, vascular, bariatric they provide to their patients. (ACS) released Optimal Resources and metabolic surgery; and Be sure to read next for Surgical Quality and Safety—a rural, pediatric, complex month’s overview of the red new manual that is intended gastrointestinal, orthopaedic, book, which will focus on to serve as a trusted resource urologic, neurological, data analytics and putting | 81 for surgical leaders seeking cardiothoracic, otolaryngology, data gleaned from clinical to improve patient care in ophthalmic, gynecologic, registries to work for quality their institutions and make and plastic surgery. improvement and patient safety. quality stick. Each month, Health care professionals Optimal Resources for Surgical the Bulletin highlights some in these and other disciplines Quality and Safety is available of the salient points made are facing increasing external for $44.95 per copy for orders throughout the “red book.” regulatory pressures. These of nine copies or fewer and demands are exerted by federal $39.95 for orders of 10 or more Increasingly, surgical care is agencies, licensing boards, copies at facs.org/redbook. ♦ provided by multidisciplinary accrediting bodies, medical teams. Thus, quality champions specialty boards, professional must be aware of the scope of organizations, health care practice, practice guidelines, institutions, and so on. Active quality improvement programs participation in the process and registries, and regulatory of improving standards of requirements unique to each care and a commitment discipline involved in the to accountability and delivery of surgical care. transparency, rather than blind Optimal Resources for Surgical submission to an increasing Quality and Safety addresses regulatory framework, will the unique characteristics be the winning strategy in the and requirements for general future. It is imperative that surgery and 19 other surgical surgeons work with internal fields, including the following: and external stakeholders, surgical oncology; trauma, including regulatory agencies, emergency general, and critical to enhance the quality and

FEB 2018 BULLETIN American College of Surgeons CLINICAL CONGRESS 2018 OCTOBER 21–25 | BOSTON CONVENTION & EXHIBITION CENTER | BOSTON, MA

THE CALL FOR ABSTRACTS AND VIDEOS IS NOW OPEN!

The American College of Surgeons Division of Education welcomes abstract submissions to the following programs:

Owen H. Wangensteen Video-Based Scientific Forum Education

• ORAL PRESENTATIONS* • VIDEO PRESENTATIONS • e-POSTER PRESENTATIONS Videos are peer reviewed and may be *Accepted authors are encouraged recommended for inclusion in the ACS to submit full manuscripts to JACS Video Library following presentation

Submission Information

• Online submissions only • Deadline: 5:00 pm (CST) March 1, 2018 • Abstract and video specifications and guidelines can be found on facs.org

2018_CC_CallForAbstracts_Bulletin_7.5x10.25in_v01.indd 1 1/11/2018 11:15:48 AM NEWS

Chapter news

by Luke Moreau and Brian Frankel

Brooklyn-Long Island Chapter: From left: Matthew Coffron, Manager of Policy Development, ACS Division of Advocacy and Health Policy; Teresa Barzyz, BLI Chapter Administrator; Jeffrey P. Weiss, MD, FACS, President, BLI Chapter; Michael Kazim, MD; Daniel Garibaldi, MD, FACS, President, Nassau Surgical Society; Mr. Buttle; and Michael Setzen, MD, FACS, Program Director | 83

York Downstate Medical Center The nearly 200 surgeons and Brooklyn-Long Island Chapter taking the top prize. A Resident residents in attendance enjoyed hosts Annual Clinic Day Abstract Poster Presentation also a day of engaging lectures, The Brooklyn-Long Island (BLI) took place, with the top 10 posters interesting research presentations, Chapter of the American College receiving special awards. The joint fellowship, and competition at of Surgeons (ACS) and the efforts of the BLI Chapter and the 10th Annual Surgical Skills Nassau Surgical Society hosted a the Nassau Surgical Society have Competition. Danbury Hospital combined Annual Clinic Day in enhanced the scope of the Annual claimed the 2017 championship. Uniondale, NY, December 6, 2017. Clinic Day for the last 15 years. The James Foster Memorial The event featured educational Lecture speaker, ACS Past- programming for 10 surgical President Gerald B. Healy, MD, specialties, with more than 400 Connecticut Chapter hosts FACS, FRCS(Hon), FRCSI(Hon), surgeons and other health care 49th Annual Meeting professor of otology and professionals in attendance. The Connecticut Chapter of laryngology, Harvard Medical The keynote speaker was the ACS hosted its 49th Annual School, Boston, MA; and the Greg Buttle, a former New York Meeting October 20, 2017, at Healy Chair in Otolaryngology Jets football player who spoke on the Marriott in Farmington. (emeritus), otolaryngologist-in- The Value of a Team. The event The meeting took place in chief (emeritus), and surgeon- included a Resident Jeopardy conjunction with the annual in-chief (emeritus), Boston Competition with winners Daniel meetings of the Connecticut Children’s Hospital, presented an Gross, MD, postgraduate year Surgical Quality Collaborative inspirational talk, The DASH Is (PGY)-4; Phil Rosen, MD, PGY- and the Connecticut Chapter of What It’s All About!, inspired by 4; and Jose Torres, MD, PGY-5, the American Society of Bariatric the Linda Ellis poem, “The Dash.” from the State University New and Metabolic Surgeons. Joseph V. Sakran, MD, MPA,

FEB 2018 BULLETIN American College of Surgeons NEWS

Connecticut Chapter: From left: Dr. Sakran; Kimberly A. Florida Chapter: Dr. Loftus (left) and Dr. Eidelson, winners of the Davis, MD, MBA, FACS, Chapter President; and Dr. Healy inaugural Surgical Skills Competition at Clinical Congress 2017

MPH, FACS, director, emergency the graduates who earn the delivered the 2017 William C. general surgery; associate chief, Chapter’s Excellence in Surgical Moore Lecture to the Indiana division of acute care surgery; Sciences award each year. Chapter November 14, 2017. and assistant professor of surgery, The Connecticut Chapter is The Moore Lecture comprises a The Johns Hopkins Hospital, planning its 2018 meeting, which nonclinical talk provided to the Baltimore, MD, presented will celebrate its 50th anniversary chapter and a scientific lecture an insightful and topical and take place October 19. to the department of surgery, afternoon lecture, Dissecting Indiana University School of 84 | Social Media—A Practical Medicine, Indianapolis. More Approach for the Surgeon. Florida Chapter residents than 70 members of the Indiana The chapter honored win Clinical Congress Chapter attended the nonclinical Scheuster E. Christie, MD, Surgical Skills Competition portion of the talk, during which FACS, St. Francis Hospital, Residents from the Florida Dr. Brunt provided insights Hartford, with its Distinguished Chapter won the inaugural gained from his mountain- Service Award in recognition of ACS Skills Competition: So You climbing experiences in the U.S. a career devoted to serving his Think You Can Operate? at the and abroad. His presentation patients and peers and inspiring Clinical Congress in San Diego to the department of surgery countless residents on their on October 22, 2017. Tyler Loftus, focused on patient safety— path to practice. David Shapiro, MD, a PGY-4 general surgery including safe cholecystectomy, a MD, MHCM, FACS, St. Francis resident at the University of movement he has championed. Hospital, presented the award Florida, Gainesville, and Sarah The lecture honors Will C. to his mentor and colleague. Eidelson, MD, a PGY-3 general Moore, MD, from Summitville, The chapter also presented surgery resident at Jackson IN. In addition to serving in all three Connecticut medical Memorial Hospital, University World War I field hospitals in schools—the Frank H. Netter MD of Miami, beat out seven teams the Argonne Forest, Verdun, School of Medicine at Quinnipiac sponsored by ACS chapters and St. Michael, he was the University, Hamden; the and residency programs. benefactor to more than 50 University of Connecticut School medical students and held of Medicine, Farmington; and positions of leadership in the the Yale School of Medicine, New Indiana Chapter hosts Muncie, IN, medical community Haven—with perpetual plaques Will C. Moore Lecturer and Indiana state organization listing the names of recent award L. Michael Brunt, MD, FACS, offices. He had an unmatched recipients. As future awards chief, section of minimally impact on surgery in Indiana, are presented, the chapter will invasive surgery, Washington performing more than 60,000 update these plaques, recognizing University, St. Louis, MO, operations throughout his career.

V103 No 2 BULLETIN American College of Surgeons NEWS

Indiana Chapter: Dr. Brunt delivering Keystone Chapter: From left: Joseph Blansfield, MD, FACS, Keystone Chapter President; the William C. Moore Lecture Dr. Pruitt; and Christopher Buzas, DO, FACS, Keystone Chapter President-Elect

poster presenters also were Medical Center, called the Keystone Chapter hosts recognized—Sinziana Cornea, business meeting to order, and annual scientific meeting BS, a medical student at Tower a new slate of chapter officers The Keystone Chapter of the Health, Reading, won first was elected, as follows: ACS hosted its annual meeting place, and Anjuli Gupta, DO, November 3, 2017 at the Lehigh a general surgery resident at • President: Jon Efron, MD, Valley Hospital’s Cedar Crest Geisinger Medical Center, FACS, Johns Hopkins campus, Allentown, PA. The Wyoming Valley, won second Medicine, Baltimore event featured a full day of place. The meeting concluded | 85 educational sessions, providing with the annual Resident Surgical • President-Elect: Jose Diaz, MD, Continuing Medical Education Jeopardy Tournament, emceed FACS, University of Maryland credits for physicians in by Christopher P. Coppola, Medical Center, Baltimore attendance. Tyler Hughes, MD, MD, FACS, a pediatric surgeon FACS, ACS Surgery News co-editor at Geisinger Medical Center, • Secretary: Joseph V. Sakran, and Editor-in-Chief of the ACS Danville. The winners of the MD, MPA, MPH, FACS, Johns Communities, and Basil Pruitt, Surgical Jeopardy tournament Hopkins Medicine, Baltimore Jr., MD, FACS, FCCM, MCCM, were Nils Tomas McBride, MD, ACS Second Vice-President, and Saranf Kashyap, MD, both • Treasurer: Jesus Esquivel, MD, were featured speakers. from Easton Hospital, PA. FACS, Surgical Specialists, A total of 30 resident abstracts Frederick Regional Health were submitted for the poster System, Frederick competition, 12 of which were Maryland Chapter holds chosen to present orally to the Fall Dinner Meeting, The group then welcomed attendees; the remaining posters elects new officers B. Todd Heniford, MD, FACS, were judged throughout the A crowd of residents and chief, division of gastrointestinal day. Cash prizes were awarded academic and community and minimally invasive surgery, to the top two oral abstract surgeons attended the Maryland and director, Carolinas Hernia competition winners—Sasha Chapter of the ACS (MD- Institute, Carolinas Health Slipak, MD, a general surgery ACS) Fall Dinner Meeting Center, Charlotte, NC, who resident at Geisinger Medical November 16 at La Scala spoke on Advances in Abdominal Center, Danville, won first place, Restaurant, Baltimore. Wall Reconstruction. and Rachel Appelbaum, MD, Following dinner, Chapter The MD-ACS 2018 Annual a general surgery resident at President Frank Rotolo, MD, Meeting is scheduled for April Lehigh Valley Health Network, FACS, Finney Trimble Surgical 28 at the Marriott Inner Harbor won second place. The top two Associates, Greater Baltimore Camden Yards, Baltimore.

FEB 2018 BULLETIN American College of Surgeons NEWS

Massacusetts Chapter: From left: Drs. Kelly, Vazquez, Cherng, and Czerniach, winners of the Massachusetts Chapter Top Gun Competition Metropolitan Philadelphia Chapter: Surgical Jeopardy winners from Drexel University, from left: Drs. Teichman, Morano, Pastrana, Schafer, Gleeson, Serniak, and Pontell

Throughout the morning, Cancer Representative, Cape Cod Residents revel at Massachusetts attendees also visited the poster Healthcare Falmouth, presented Chapter’s 64th Annual Meeting hall to speak with the 40 authors four awards on behalf of the The Massachusetts Chapter of about their work. The Basic ACS Commission on Cancer. the ACS (MCACS) held its 64th Science Poster of Distinction Recipients were Mallika Gopal, Annual Meeting December 2 at Award was presented to Shen third-year medical student, Boston the Westin Copley in Boston, Li, MD, resident, Massachusetts University School of Medicine, for with a record registration of General Hospital, Boston, Impact of Subtype and Location 86 | 168 professionals, including 93 for Pioglitazone Reduces on Pathological Upstaging of residents. Chapter President Hepatocellular Neoplasia in a Clinical T1b/T2N0 Esophageal Anne C. Larkin, MD, FACS, Rat Model of Cirrhosis. The Cancer; Abha Aggarwal, PhD, recognized Program Chair Clinical Poster of Distinction MSPH, MS, Brigham and Robert P. Driscoll, MD, Award was presented to Rajshri Women’s Hospital, for Metabolic FACS, for putting together a Mainthia, MD, Massachusetts Inhibition of Anaplastic Thyroid valuable program addressing General Hospital, for Malpractice Cancer with 3-BP Depends on health care disparities. Claims after Cholecystectomy: Hexokinase II Expression; Praveen The day opened with two What Factors Are Associated Sridhar, MD, PGY-2 resident, sessions showcasing 12 resident with Plaintiff Payout? Boston University, for Pre-Clinical research papers. The 5th Joseph The meeting also featured Evaluation of Spliceosome and Murray Resident Research Basic the Survivor Game, which Proteasome Inhibition in Triple Science Award was presented was moderated by George C. Negative Breast Cancer; and to Sameer Hirji, MD, general Velmahos, MD, PhD, FACS, Gabriel J. Ramos-Gonzalez, MD, surgery resident, Brigham division chief of trauma, PGY-2 surgical research fellow, and Women’s Hospital, for emergency surgery, and surgical Boston Children’s Hospital, Utility and Feasibility of Intra- critical care, Massachusetts for Long-Term Outcomes and Post-Operative Crisis General Hospital, using an of Liver Transplantation for Management Checklists in audience response system Hepatoblastoma: A Single- Cardiac Surgery. The Resident accessed through attendees’ Center 14-Year Experience. Research Clinical Award was smartphones to vote participants The meeting concluded with presented to Janaka Lagoo, “off the island.” The winner the seventh annual Resident MD, resident, Ariadne Labs, was David Harris, MD, Top Gun Competition, where Boston, for Physicians Working PGY-3 resident, Brigham surgical residents’ laparoscopic in New Hospital Environments: and Women’s Hospital. skills, including intracorporeal Understanding Their Challenges Peter S. Hopewood, MD, knot tying, transferring of objects to Develop Real Solutions. FACS, ACS Commission on from one hand to another, and

V103 No 2 BULLETIN American College of Surgeons NEWS

Nevada Chapter: From left: Drs. McNickle, McNicoll, Chestovich, Rivera, and Kuhls

pattern cutting, were judged. Drexel, composed of Elizabeth Nevada ACS COT first-place The winning individual on the Gleeson, MD; William Morano, winner; Christopher McNicoll, initial four tasks was Mohamad MD; Marlon Pastrana, MD; MD, MPH, MS, UNLV SOM Abdulhai, MD, general surgery Matthew Pontell, MD; Charles general surgery resident and resident, Lahey Hospital and Schafer, DO; Nicolas Serniak, Nevada ACS COT second-place Medical Center, Burlington. MD; and Amanda Teichman, winner; and Nancy Rivera, MD, Following the final “surprise” MD, walked away as the 2017 UNLV SOM acute care surgery task, the winning team of the Surgical Jeopardy Champions. fellow. Both Chapter President coveted MCACS Top Gun trophy Other competing Deborah Kuhls, MD, FACS, and | 87 was from UMass Memorial Philadelphia institutions Paul Chestovich, MD, FACS, Medical Center, led by residents included Abington, Einstein, trauma surgeon and assistant Donald R. Czerniach, MD; Nicole Jefferson, Lankenau, Philadelphia professor, department of surgery, Cherng, MD; John Kelly, MD; College of Osteopathic UNLV School of Medicine, and Samuel Vazquez, MD. Medicine, Temple, and the spoke at the Trauma Winter University of Pennsylvania. Conference on firearm injuries and reducing pediatric computed Metropolitan Philadelphia tomography scans, respectively. Chapter hosts Third Annual Nevada Chapter attends Jeopardy Tournament trauma meeting in Hawaii The Metro Philadelphia Chapter Several members of the Nevada New Hampshire of ACS (MPACS), PA, hosted Chapter of the ACS traveled to rejuvenates chapter its Third Annual Jeopardy the Trauma Winter Conference/ The New Hampshire Chapter Tournament November 9 at the ACS Committee on Trauma of the ACS convened an National Mechanics restaurant. A Region IX Resident Papers organizational meeting at total of 60 residents and MPACS Competition December 8, 2017, Clinical Congress 2017 to discuss Fellows were in attendance as the hosted by the Hawaii Chapter rejuvenation of the chapter. nine jeopardy teams fought for the of the ACS at The Queen’s All New Hampshire Chapter coveted trophy. Jeffrey Butcher, Medical Center, Honolulu. members were then invited to MD, FACS, MPACS President, Representing the Nevada attend the Annual Meeting of was the emcee, and Robert Chapter in the Resident Papers the Massachusetts Chapter in Kucejko, MD, MPACS Resident Competition were the following: Boston on December 2, 2017. The Subcommittee Chair, coordinated Allison McNickle, MD, University chapter hopes to partner with the event. Eight Philadelphia- of Nevada, Las Vegas, School other New England chapters for based institutions competed in of Medicine (UNLV SOM), additional events in the future this year’s tournament. Team acute care surgery fellow and while it builds momentum.

FEB 2018 BULLETIN American College of Surgeons NEWS

New Mexico Chapter: Front row, from left: Drs. Fahy, Remillard, Bass, Vigil, and McKee. Back row: Drs. Batley, Rajput, Kwan, Yeats, and Pitcher.

The New Hampshire Chapter Center, Camden; Bronx-Lebanon The keynote speaker was is seeking enthusiastic Hospital Center; Morristown Rachel R. Kelz, MD, FACS, individuals to play a leadership Medical Center; Rutgers associate professor of surgery, role in its revitalization. New Jersey Medical School, University of Pennsylvania, Newark; Rutgers Robert Wood Philadelphia. Dr. Kelz’s topic Johnson Medical School, New was E-IQ: Education, Innovation New Jersey Chapter Brunswick; and Saint Barnabas and Quality. The topic was hosts the 66th Annual Medical Center, Livingston. well received and those in 88 | Clinical Symposium Residents from Bronx Lebanon attendance participated in an The New Jersey Chapter of the Medical Center won for the interactive exercise on IQs. ACS hosted its 66th Annual second consecutive year. The 2017 Sheen Award Clinical Symposium December A surgical resident poster recipient, Melina Kibbe, MD, 1, 2017, at The Renaissance and manuscript contest took FACS, chair, department of Woodbridge Hotel & Conference place. The winners were surgery, and the Zach D. Center in Iselin, NJ. More Robin F. Irons, MD, Cooper Owens Distinguished Professor, than 200 surgeons, surgical University Hospital, Camden, University of North Carolina residents, and medical students for Acceleration of Diabetic at Chapel Hill, attended the attended the meeting. Wound Healing with Adipose awards dinner Friday evening Specialty surgical sessions Derived Stem Cells, Endothelial and presented the lecture When centered on bariatric/foregut Differentiated Stem Cells and Mice Are Men, which focused surgery, colon/rectal surgery, Topical Conditioned Medium on the difference between drug global surgery, plastic surgery, Therapy in a Swine Model; trials between men and women. transplant and hepato-pancreato- Mihir M. Shah, MD, Rutgers A brief business meeting was biliary surgery, trauma and Cancer Institute of New Jersey, conducted during which the thoracic surgery, urologic for Comparison of Perioperative following new chapter officers surgery, and vascular surgery. Chemotherapy vs. Postoperative were elected (all MD, FACS): Additionally, the surgical Chemoradiation Therapy Justin T. Sambol, President; residency directors met. for Distal Gastric Cancer: Joseph E. Cauda, President- The event featured Surgical An Analysis of the National Elect; Anne C. Mosenthal, Jeopardy for the surgical Cancer Database; and Anthony Vice-President; Dr. Lazar, residents, with Eric Lazar, Scholar, MD, MBS, Rutgers, Secretary; and Robert M. MD, FACS, a pediatric surgeon New Jersey Medical School, Olson, Treasurer. The meeting in Morristown, moderating. for Improving Cancer Patient concluded with a presentation Participating teams included Emergency Room Utilization: A on the extensive legislative Cooper University Health New Jersey State Assessment. review by the chapter lobbyist.

V103 No 2 BULLETIN American College of Surgeons NEWS

Wisconsin Chapter: From left (all MD, FACS): Brian Lewis, President-Elect; Shanu Kothari, ACS Governor; Michael Garren, Immediate Past-President; David Schultz, President; and Barbara Boyer, Secretary-Treasurer

who presented Approaching New Mexico Chapter holds State the Complex Ventral Hernia Wisconsin Surgical Society of Surgical Science Meeting Patient. The Annual Resident holds Annual Conference The 2017 State of Surgical Abstract Competition took place Sen. Ron Johnson (R-WI) Science Meeting of the New during the meeting, and Alissa held a town hall meeting Mexico Chapter of the College Greenbaum, MD, and Jaideep November 3, 2017, as part of (NMACS) took place September Das Gupta, MD, both from the the Annual Conference and 8–9, 2017, in Albuquerque. University of New Mexico School Meeting of The Wisconsin Anthony Vigil, MD, FACS, of Medicine, tied for first place. Surgical Society—a Chapter of | 89 NMACS President, and Jean This year’s program included ACS. After some brief comments, Remillard, MD, FACS, NMACS a Surgical Jeopardy competition. the senator opened the floor for President-Elect, led the event. Three teams from the University questions. Topics were wide- The NMACS welcomed Barbara of New Mexico participated ranging, including health care L. Bass, MD, FACS, FRCS(Hon), in this event. Zoe Jones, MD, reform and tort reform. The then President-Elect of the ACS, won the competition and a trip gathering of more than 150 as the keynote speaker. She to Clinical Congress 2017. people found the session to presented Retooling Reimagined: The chapter elected its be valuable and interesting. Building the Infrastructure 2017–2018 officers and council The meeting took place at the to Support a Lifetime of High members during the annual American Club, Kohler, WI. Performance Surgery. The business meeting. Dr. Remillard NMACS welcomed many other was elected President; Bridget speakers from the University Fahy, MD, FACS, was elected Chapter Speed Networking: of New Mexico School of President-Elect; Chayanin Clinical Congress 2017 Medicine, Albuquerque, Musikasinthorn, MD, FACS, A Chapter Speed Networking including Ashwani Rajput, was elected Vice-President; and event took place October 23 MD, FACS, who presented Albert Kwan, MD, FACS, agreed at Clinical Congress 2017. the Commission on Cancer to another term as Secretary- Approximately 70 chapter leaders update; Victor Phuoc, MD, Treasurer. Rohini McKee, MD, and administrators from around who presented Robot-Assisted FACS; Kamran Kamali, MD, the world were invited to learn Surgery for Gastrointestinal FACS; Ashwani Rajput, MD, more about how to strengthen Oncology; David Pitcher, MD, FACS; and Jerry Batley, MD the activities of their local FACS, ACS Governor, who FACS, were elected councilors. chapters. The event offered a presented the Merit-based A joint meeting with the fun, fast-paced educational and Incentive Payment System; New Mexico Medical Society social environment for sharing and Heidi Miller, MD, FACS, is planned for September. best practices on topics such

FEB 2018 BULLETIN American College of Surgeons NEWS

South Korea Chapter: Dr. Bass (center) with leaders of the South Korea Chapter of ACS and the Korean Surgical Society

as membership recruitment, other complex therapies. Plenary Surgical Society, founded in engagement of members of the lectures were intermixed with 1947. To increase international Young Fellows Association and educational sessions and offered networking, the Korean Surgical the Resident and Associates opportunities for surgeons to Society works with the South Society, social media, advocacy, discuss the hot topics in surgery Korea Chapter of ACS, Japan and dynamic meetings. and for scientists to present their Surgical Society, and numerous Chapters discussed similar devices and innovative work. other international surgical experiences, and one of the After the inauguration of the organizations to improve 90 | benefits of the event was that it Kuwait Chapter on September 30, the quality of education. provided a forum for building the delegates and the organizing The mission of the South lasting connections with committee were invited to a Korea Chapter of ACS, which was members of other ACS chapters. special event at the Bayan Palace. formed in 1987, and the Korean On November 25, 2017, the Surgical Society is to improve the Kuwait Chapter also organized quality of patient care, which will Kuwait Chapter hosts an Advanced Laparoscopy contribute to the advancement inaugural meeting Suturing Course for surgeons of public health in South Korea. The Kuwait Chapter of the ACS from all surgical subspecialties. hosted its inaugural Chapter Conference, September 28– The College welcomes a new October 1, 2017, with the theme Korean Surgical Society and international chapter of Education and Innovation. South Korea Chapter of ACS The ACS welcomes the Qatar Surgeons of all specialties in hold Annual Congress Chapter to its international Kuwait attended the event. Dr. Bass attended the Annual chapter network. The ACS Board Notable guests included Courtney Congress of the Korean Surgical of Regents officially granted a M. Townsend, Jr., MD, FACS, Society and South Korean charter to the Qatar Chapter at then-ACS President, and Carlos Chapter of ACS, which took its October 2017 meeting in San A. Pellegrini, MD, FACS, place November 2–4, 2017, in Diego, CA. The Qatar Chapter FRCSEd(Hon), FRCSEng(Hon), Seoul, South Korea. Dr. Bass will work with the College to FRCSI(Hon), ACS Past-President. provided an ACS update and gave provide opportunities for ACS The conference promoted a lecture, Retooling Reimagined: members in Qatar to get involved innovation in surgery, one of Building the Infrastructure at the local level. The addition the challenges in modern health to Support a Lifetime of High of the Qatar Chapter increases care, and provided an evidence- Performance in Surgery. the worldwide network of ACS based approach to addressing the Dr. Bass recognized the chapters to 112—45 international real challenges in surgery and 70th anniversary of the Korean and 67 domestic chapters. ♦

V103 No 2 BULLETIN American College of Surgeons

GLOBAL NEEDS. GLOBAL SURGEONS. GLOBAL OUTREACH.

Feel the power of volunteerism. Change your community and change yourself.

Inspired to address challenges the underserved faced in their own community when requiring surgical care, Drs. Schecter (above) and Grey co-founded Operation Access in 1993. This organization provides donated outpatient surgeries and specialty care to the under- and uninsured. It is a model for surgical care delivery to the underserved throughout the U.S. today.

Making a difference in your own backyard starts with one step forward. One personal challenge. One decision to give back. facs.org/ogb

2017_MS_OGB_Bulletin_FullPage_Domestic_7.5x10.25in_v01.indd 1 11/17/2017 11:57:54 AM NEWS

ACS in the

Editor’s note: Media around the world, including social Gunshot sensors improve Acoustic gunshot sensors media, frequently report on odds for shooting victims help speed treatment American College of Surgeons Philadelphia Inquirer, of shooting victims (ACS) activities. Following are October 24, 2017 Yahoo! Finance, October 25, 2017 brief excerpts from news stories “Gunshot sensors may help “Acoustic gunshot sensors covering research and activities speed treatment of shooting have been pinpointing shooting from the ACS Clinical Congress victims and potentially scenes and victims for years. The 2017, held in San Diego, CA, improve outcomes for those tech can be found in around 90 October 22–26. To access the with the most serious injuries, U.S. cities in total. Meanwhile, 92 | news items in their entirety, visit a new study suggests. the American military has been the online ACS Newsroom at About 90 U.S. cities have using it to track down the source facs.org/media/acs-in-the-news. installed the sensors to help of gunshots on the battlefield pinpoint shooting scenes and find since 2011. But, the effectiveness victims. Fewer than 20 percent of of the sensors in saving the shots fired are reported to police, lives of ordinary citizens has according to the researchers.” never been quantified. That’s all changing, courtesy of a new study by surgeons at the University Surgery process maps may of California, San Francisco- reduce infection risks in East Bay. The key finding from low resource settings the analysis of shooting victims Medscape, October 24, 2017 (identified through the sensors) “Process maps can reduce the is that the tech is potentially risk for perioperative infection beneficial for those who have in low-income countries by suffered serious injuries.” pinpointing barriers to good procedures, researchers say. A process map implemented Checklist aims to help prevent at a pilot site in Jimma, Ethiopia, surgical infections in Africa significantly improved such Scope, October 26, 2017 measures as hand-washing and the “For the last year, Stanford timing of prophylactic antibiotics, surgery resident Jared Forrester, said Jared Forrester, MD, a surgical MD, has been living in Ethiopia, fellow at Stanford Health Care tackling one of surgery’s in Palo Alto, [CA]. ‘This can most troubling issues—how be a powerful tool,’ he said.” to prevent infections after an

V103 No 2 BULLETIN American College of Surgeons NEWS

operation. Infection is always But the study presented had emergency surgery a risk with surgery, but those at the American College of and underwent [computed risks can be as much as five Surgeons Clinical Congress tomography] scans of the times higher among patients in San Diego found the vast abdomen and pelvis before in low- and middle-income majority of these women surgery. These scans were countries, Forrester said.” choose not to get it.” used to calculate waist-to- hip ratios, a measure of belly fat. A healthy ratio should not Many high-risk women skip Treating appendicitis without exceed .90 in men and .85 in breast cancer screenings, surgery: Fears raised women, according to the World even if they’re free Medscape, October 27, 2017 Health Organization.” ♦ | 93 United Press International, “By managing older, sicker October 26, 2017 patients’ appendicitis without “Knowing they’re at surgery, U.S. physicians may be increased risk for breast cancer increasing their risk for death isn’t enough to persuade many by a slight but statistically women to get [magnetic significant degree, data suggest. resonance imaging] screenings— ‘Mortality, we were surprised even if they’re free. to find, was significantly Researchers studied more higher in the patients managed than 1,000 women in a U.S. nonoperatively,’ said lead author military health system who had a Isaiah Turnbull, MD, PhD, 20 percent or greater lifetime risk [FACS,] an assistant professor of breast cancer due to genetics of surgery at Washington or personal or family history.” University in Saint Louis, [MO].”

More than 80% of women Belly fat widens odds of with a high risk of breast emergency surgery troubles cancer are not getting Health, October 30, 2017 screened, study warns “Excess belly fat Daily Mail, October 27, 2017 dramatically increases the “Earlier MRI screening risk of complications and is recommended for women death after emergency with genetic predisposition to surgery, a new study finds. breast cancer, or personal or The research included family history of the disease. more than 600 patients who

FEB 2018 BULLETIN American College of Surgeons NEWS

Call for nominations for the ACS Board of Regents and ACS Officers-Elect

The American College underrepresented minorities of Surgeons (ACS) 2018 for all leadership positions. Call for nominations for Nominating Committee of Board of Regents the Fellows (NCF) and the All nominations must The 2018 NCBG will select Nominating Committee of the include the following: nominees for pending Board of Governors (NCBG) vacancies on the Board of will be selecting nominees • A letter/letters of nomination Regents to be filled at Clinical for leadership positions in Congress 2018. The deadline the College as follows. • A personal statement from for submitting nominations the candidate detailing his or is February 23, 2018. her ACS service and interest Call for nominations in the position (for President- Criteria for Officers-Elect Elect position only) The NCBG will use the The 2018 NCF will select following guidelines nominees for the three • A current curriculum vitae (CV) when considering Officer-Elect positions of potential candidates: the ACS: President-Elect, • The name of one individual 94 | First Vice-President-Elect, who can serve as a reference • Nominees must be loyal and Second Vice-President- members of the College Elect. The deadline for Further details who have demonstrated submitting nominations Entities such as surgical outstanding integrity along is February 23, 2018. specialty societies, ACS with an unquestioned devotion Advisory Councils, ACS to the highest principles Criteria for consideration committees, and ACS chapters of surgical practice. The NCF will use the following that would like to provide guidelines when considering a letter of nomination must • Nominees must have potential candidates: provide a description of their demonstrated leadership selection process and the total qualities, such as service • Nominees must be loyal list of applicants reviewed. and active participation on members of the College who Any attempt to contact ACS committees or in other have demonstrated outstanding members of the NCF by a components of the College. integrity and an unquestioned candidate or on behalf of devotion to the highest a candidate will be viewed • The ACS encourages principles of surgical practice. negatively, and may result in consideration of women and disqualification. Applications underrepresented minorities • Nominees must have submitted without the for all leadership positions. demonstrated leadership requested information qualities, such as service will not be considered. • The NCBG recognizes the and active participation on Nominations importance of the Board ACS committees or in other must be submitted to of Regents representing all components of the College. officerandbrnominations@facs. who practice surgery in both org. If you have any questions, academic and community • The ACS encourages contact Emily Kalata at 312- practice, regardless of practice consideration of women and 202-5360 or [email protected]. location or configuration.

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• Nominations are open to surgeons • A letter of nomination a candidate or on behalf of of all specialties, but particular a candidate will be viewed consideration will be given • A personal statement from the negatively, and may result in this nomination cycle to those candidate detailing his or her ACS disqualification. Applications in the following specialties: service and interest in the position submitted without the requested information ȖȖ Burn and critical care surgery • A current CV will not be considered. ȖȖ Gastrointestinal surgery Nominations ȖȖ General surgery • The name of one individual may be submitted to ȖȖ Surgical oncology who can serve as a reference officerandbrnominations@facs. ȖȖ Transplantation org. If you have any questions, ȖȖ Trauma Further details contact Emily Kalata at 312- ȖȖ Vascular surgery Entities such as surgical 202-5360 or [email protected]. specialty societies, ACS Advisory For information only, the • Only individuals who are Councils, ACS Committees, current members of the Board of currently and are expected and ACS chapters that would Regents who will be considered to remain in active surgical like to provide a letter of for re-election are (all MD, practice for their entire nomination must provide FACS): John L. D. Atkinson, | 95 term may be nominated at least two nominees and a James C. Denneny III, Timothy for election or reelection description of their selection J. Eberlein, Henri R. Ford, to the Board of Regents. process, along with the total Enrique Hernandez, L. Scott list of applicants reviewed. Levin, Linda Phillips, Anton All nominations must Any attempt to contact A. Sidawy, Beth H. Sutton, include the following: members of the NCBG by and Steven D. Wexner. ♦

Stand out in 2018—update your ACS member profile Freshening up your online presence is one resolution that will be easy to keep in 2018 for members of the American College of Surgeons (ACS). It takes fewer than 30 minutes to update your online ACS member profile. Your ACS member profile allows you to maintain a professional presence online and easily connect with your colleagues. Your patients can visit your profile to learn more about you, and it will help potential patients find you. Personalize your profile with information about your practice, your education and training, areas of clinical concentration, and your board certifications and society memberships. Add a link to your practice website and a photo. Find more information on the benefits of keeping an up-to-date profile at facs.org/updateyourprofile. To update your profile today, log in to the ACS website at facs.org using your member login information. Click on My Profile in the blue navigation bar and select My Profile Overview. Click on the pencil icon in the top right corner of each section to edit. Be sure to save your changes before moving on to the next section. Contact [email protected] for assistance. ♦

FEB 2018 BULLETIN American College of Surgeons NEWS

Nominations for 2018 volunteerism and humanitarian awards due February 28

The American College of in which one’s time or talents received compensation for Surgeons (ACS), in association are donated for charitable this work does not preclude a with Pfizer, Inc., is accepting clinical, educational, or other nominee from consideration nominations for the 2018 worthwhile activities related and, in fact, may be expected Surgical Volunteerism Award(s) to surgery. Volunteerism in based on the extent of the and Surgical Humanitarian this case does not refer to professional obligation. Award. All nominations must be uncompensated care provided Nominations will be received by February 28, 2018. as a matter of necessity in most evaluated by the ACS Board clinical practices. Instead, of Governors Surgical volunteerism should be Volunteerism and Humanitarian Volunteerism Awards characterized by prospective, Awards Workgroup, and The ACS/Pfizer Surgical planned surgical care to their selections will be Volunteerism Award—offered underserved patients with no forwarded to the Board in four potential categories anticipation of reimbursement of Governors Executive annually—recognizes surgeons or economic gain. Committee for final approval. 96 | who are committed to giving back to society by making significant contributions to Humanitarian Award Nominations surgical care through organized The ACS/Pfizer Surgical The following conditions apply volunteer activities. The awards Humanitarian Award to the nominations process: for Domestic, International, recognizes an ACS Fellow and Military Outreach are whose career has been dedicated • Self-nominations are permissible intended for ACS Fellows in to ensuring the provision of but require at least one active surgical practice whose surgical care to underserved outside letter of support volunteer activities go above and populations without beyond the usual professional expectation of commensurate • Renomination of previous commitments or retired Fellows reimbursement. This award nominees is acceptable who have been involved in is intended for surgeons who but requires completion volunteerism during their active have dedicated a significant of a new application practice and into retirement. portion of their surgical careers Resident Members and Associate to full-time or near full-time Plan to spend a minimum of Fellows of the ACS who have humanitarian efforts, rather 30 minutes completing the been involved in significant than routine surgical practice. application form. For the surgical volunteer activities Examples include a career nominee to have a fair review, during their postgraduate dedicated to missionary surgery, detailed information is required, surgical training are eligible for the founding and ongoing including the following: the Resident award. Surgeons operations of a charitable of all specialties are eligible organization dedicated to • Demographic information about for each of these awards. providing surgical care to the the nominee and nominator. For the purposes of these underserved, or a retirement awards, “volunteerism” is characterized by surgical • Details about the nominator’s defined as professional work volunteer outreach. Having relationship with the nominee,

V103 No 2 BULLETIN American College of Surgeons NEWS

along with background been involved in, and any • The nomination form does information on the additional roles they have not need to be completed in nominee’s surgical career. played, among other items. one sitting. You can start an application and then come back • Completion of narrative • It helps to tell a story with your to enhance it with additional/ sections requesting detailed nomination. Specific examples more detailed information information about the and anecdotes are encouraged. obtained about the nominee. nominee’s volunteerism or humanitarian work, including • The information you The nomination website the type of service they provide will be shared with can be accessed through the provide, the sustainability your nominee during our Operation Giving Back (OGB) of the programs they are verification process. It may be section of the ACS website at facs. involved in, any advocacy worthwhile to obtain input org/ogb. For more information, efforts they may have from the nominee in advance. contact OGB at [email protected]. ♦

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Apply for International Scholarships for Surgical Education by March 1

The American College of interest areas in surgical and evaluation of education Surgeons’ (ACS) Division of education and training. At modules, use of novel teaching Education and the International the conclusion of the Clinical and assessment strategies, or Relations Committee have Congress and his or her visits to curriculum design. In addition, announced three international the ACS-accredited Education applicants must submit a one- scholarships focused on surgical Institutes, each scholar will send paragraph description of their education. All application to the International Relations education philosophies, a list materials and supporting Committee and to the Division of specific educational goals documents are due no later than of Education a brief report and objectives for their visits, March 1, 2018, for attendance outlining the outcomes that and evidence of support of at Clinical Congress 2018, have been achieved as a result these goals and objectives from October 21−25 in Boston, MA. of the scholarship, specifically the leadership at their home These awards will offer focusing on achievement of institutions. These documents faculty members from the objectives outlined in their will be reviewed by the Division countries other than the U. S. scholarship application. The of Education as part of the and Canada the opportunity scholarships will facilitate selection process. At least five to participate in a variety of the scholars’ involvement years of experience is required 98 | faculty development activities in subsequent collaborative beyond completion of all training to obtain new knowledge and ventures in education and and fellowships. Scholarships skills in surgical education and training under the aegis of the must be used in the year awarded; training, which will be useful ACS Division of Education. they may not be postponed. in improving surgical education Each scholarship provides a Full scholarship requirements and training in the scholar’s stipend of $10,000, supporting for this program may be home institution and country. travel and per diem in North reviewed at facs.org/member- The scholars will participate America, and the cost of services/scholarships/international/ in the annual ACS Clinical courses undertaken at the issurged. The application for the Congress, including the Surgical Clinical Congress and at the scholarship can be accessed at Education: Principles and ACS-accredited Education the bottom of the requirements Practice course, as well as other Institutes to be visited. Clinical page. Questions should be plenary sessions and courses that Congress registration and fees directed to the ACS International address surgical education and for attendance at the Surgical Liaison at [email protected]. ♦ training across the continuum Education: Principles and Practice of professional development. course will be provided gratis. This continuum includes the Assistance will be offered to needs of practicing surgeons reserve affordable housing in throughout their entire careers, the Clinical Congress host city. as well as the needs of residents, medical students, and other members of the surgical team. Requirements Following the Clinical Applicants must provide Congress, each scholar will documentation of prior visit two Level I ACS-accredited experience in surgical Education Institutes selected in education and training, such as advance based on the scholars’ involvement in the development

V103 No 2 BULLETIN American College of Surgeons American College of Surgeons Insurance Program

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*Dates and locations subject to change. For more information on College events, visit www.facs.org/events or facs.org/member-services/chapters/meetings.

South Texas Chapter Florida Chapter FEBRUARY February 22–24 April 6–7 Houston, TX Orlando, FL 2018 ACS Coding and Contact: Janna Pecquet, Contact: Brian Hart, Reimbursement Workshop [email protected], [email protected], February 8–10 www.southtexasacs.org floridafacs.org Las Vegas, NV Contact: KarenZupko & Associates, Inc., 2018 ACS Coding and Northern California Chapter [email protected], Reimbursement Workshop April 6–7 www.karenzupko.com/workshops2/ February 22–23 Berkeley, CA gensurg-workshops/ Orlando, FL Contact: Christina McDevitt, Contact: KarenZupko & Associates, Inc., [email protected], www.nccacs.org Georgia Lobby Day [email protected], February 14 www.karenzupko.com/workshops2/ Ohio Chapter Atlanta, GA gensurg-workshops/ April 6–7 Contact: Kathy Browning, Cincinnati, OH [email protected], Contact: Emily Maurer, georgiaacs.org/ [email protected], 100 | MARCH www.ohiofacs.org United Arab Emirates Chapter February 15–17 Oregon Lobby Day North and South Dubai, UAE March 4 Dakota Chapters Contact: Agustina Dagus, Salem, OR April 13–14 [email protected] Contact: Harvey Gail, Deadwood, SD [email protected], Contact: Terry Marks, North Texas Chapter www.oregonchapteracs.org [email protected] February 16 marylandacs.org/ Dallas, TX Peru Chapter Contact: Carrie Steffen, March 14–16 [email protected], Lima, Peru www.ntexas.org/ Contact: Dr. Jaime Herrera-Matta, FUTURE CLINICAL [email protected] Indiana Lobby Day CONGRESSES February 20 2018 Indianapolis, IN October 21–25 Contact: Tom Dixon, APRIL Boston, MA [email protected] Japan Chapter 2019 Arkansas Lobby Day April 5–7 October 27–31 February 21 Tokyo, Japan San Francisco, CA Little Rock, AR Contact: Dr. Yoshida Kazuhiko, Contact: Linda Gist, [email protected] 2020 [email protected] October 4–8 Chicago, IL

V103 No 2 BULLETIN American College of Surgeons