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July 7, 2011


A neglected disease, surgeon says

Andrew B. Peitzman

Andrew B. Peitzman

Trauma represents the nation’s No. 1 health care cost, with a price tag of $700 billion; injuries are the leading cause of death in people age 45 and younger.

Still, “trauma remains a neglected disease in our society,” said medical school professor Andrew B. Peitzman in a June 30 Provost’s Inaugural Lecture celebrating his appointment as the Mark M. Ravitch Endowed Chair in Surgery.

“I think people tend to be fatalistic, that these things are unavoidable — they’re not. And they think these things won’t happen to themselves or the people they care about. That’s not true. They will happen to people you know and love and care about,” he said.

“All of us have a role in preventing these injuries,” he said, citing gun safety, avoidance of drinking and driving, wearing seatbelts, ensuring safety in the home for the elderly and teaching kids to swim as just some of the ways to reduce trauma injuries.

Peitzman, an internationally acclaimed trauma surgeon, noted that it is intentional that “trauma,” rather than “accident,” is the medical term used, “because the injury is generally avoidable.

“We know that in general heart disease and cancer kill more people but what trauma does is steal decades of life from our young people.” And trauma remains a germane issue as the American population ages, Peitzman said, noting that falls have surpassed motor vehicle crashes as the chief cause of injury in recent years.

A broader issue is that emergency care, “especially emergency surgical care, is in crisis mode in this country right now,” due in part to overcrowded emergency rooms and a shortage of surgeons, he said.

A 2006 Institute of Medicine report recommended regionalizing on-call specialty services — a model similar to the system in place locally in which the UPMC Presbyterian trauma center serves patients from across roughly one-third of the state of Pennsylvania.


Peitzman described a “perfect storm” brewing in light of an aging population that likely will need more operations, combined with fewer surgeons — especially general surgeons, whose numbers have declined 25 percent over the last quarter century.

“We’re really not producing general surgeons at anywhere near the rate that we were before and as the baby boomers get older, we’re certainly not replacing all the general surgeons that are currently in practice.”  In spite of the growing need, the number of general surgeons trained each year has remained for decades at 1,000, he said, adding that even that figure is misleading because 70-80 percent of them go on to specialize rather than practice as general surgeons.

Globally, the problems are even more severe, Peitzman said, citing five million deaths worldwide and another 15-20 million permanent disabilities due to injuries each year.

He said most motor vehicle crashes and homicides occur in low- to middle-income countries, and that the incidence of unintentional injury in children differs by a factor of 5:1 or 6:1 between low- and high-income countries.

“It’s a huge problem,” he said.

Interpersonal violence also is much more common globally, with rates in Latin America roughly six times greater than in the United States. “You really can’t appreciate the magnitude of the violence until you’ve been there and seen it,” said Peitzman, who has been involved in working in Latin America for 20 years.

An even larger issue than preventing injury, he said, is that some three billion people have no access to surgical care.

For example, hernia is the top cause of bowel obstruction in Africa, he said. “If you have a strangulated hernia in Africa, you die from it. It’s a lethal disease because people can’t get the operations that they need.”  Similarly, “pregnancy is a dangerous disease,” with a half- million women worldwide dying each year for lack of surgical care such as Caesarean sections.

“Surgery really has to be part of a public health initiative. It really extends far beyond treating injuries,” he said.

The International Association for Trauma Surgery and Intensive Care, the International Society for Surgery and the World Health Organization (WHO) have taken aim at the problem through their essential trauma care project, which outlines basic trauma care and the resources needed to construct a trauma system.

Some of the needs are simple and inexpensive — for instance, teaching basic first aid in rural clinics and procedures such as intubation and how to clamp arteries in larger hospitals.

“These are very elementary things that would make an enormous difference in saving lives where injury is basically epidemic,” he said.

Similarly, WHO’s global initiative for emergency and essential surgical care is making progress in building capacity and improving care services worldwide.

“Surgery needs to be recognized as a global health care intervention,” Peitzman said, noting that WHO highlighted surgery as a cost-effective public health intervention comparable to vaccination.

Simple skills such as treating wounds, repairing hernias, performing Caesarean sections and inserting chest tubes “are the things we need to promulgate in the one-third of the world that has no access to basic surgical needs,” he asserted.

Urging local colleagues to continue to work with their international colleagues, he said, “It really is something that we need to pay attention to and we’re all part of the solution.”

In closing, Peitzman offered advice to medical students and residents: “I think as a physician you are obligated to fulfill three missions: One is provide the best care you possibly can. Second, do the studies that make a difference — that change how people treat patients, and recognize we are a global village. Embrace that and be part of the solution globally,” he said.

“I can tell you that the satisfaction and reward is immeasurable.”

—Kimberly K. Barlow

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