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Organization andTraining inTrauma

andAcute Care Surgery inItaly

The last three decades experienced a remarkable improvement in the quality of trauma care in Italy, with the contribution of many professionals from different elds: anesthesiology, surgery, emergency medicine, orthopedics, neurosurgery, plastic-reconstructive surgery, radiology, nursing, rehabilitation, administration, and politics. The idea of an integrated system between the community and the hos­pitals for emergencies originated in Bologna, with the terrorist attack at the train station on August 2, 1980, with more than 80 deceased and 200 injured. The city’s health system was immediately overwhelmed by the number of wounded: many injured victims were transported by private cars, taxi and bus, and hospitals were not organized for the reception and treatment of patients. It was evident that an emergency dispatch center for coordination, the availability of a consistent number of ground and air ambulances and a network of hospitals for trauma were manda­tory. Ten years later, still in Bologna, a rst emergency dispatch center was set up during the Soccer World Championships. At the same time, in Friuli Venezia Giulia, a region of Italy’s North-East, the area of the city of Gorizia was equipped with an operational center for emergencies. In 1992, the Italian Government promulgated a law (DPR 27-3-1992) which instituted a telephone number for health emergencies (“118”). At the end of the twentieth century two studies [1, 2] demonstrated a high number of potentially or frankly preventable trauma deaths in two urban areas of Italy, Parma and Milan. These data prompted the Ministry of Health to draft a

document regarding the need for an integrated trauma system with a dispatch center and a network of hospitals with different levels of resources available for trauma care (Superior Health Council, 2006). Some Regions in the country started to orga­nize themselves to this end and hospitals in Milan, Bologna, and Rome set up spe­cic services for trauma care. The Milan trauma service was directed by surgeons, while the leadership in Bologna and Rome was held by anesthesiologists. Many scientic Societies were involved in spreading the culture of trauma, and a small group of passionate doctors organized three to ve Trauma Update meetings every year around the country. International experts in traumatology were invited to join and these meetings were instrumental in establishing partnerships between Italian doctors and world-renowned trauma centers. Famous trauma and acute care sur­geons from other countries, such as Tom Scalea, Sharon Henry (Baltimore, USA), Ernest Moore, Walter Bif (Denver, USA), Demetrios Demetriades (Los Angeles, USA), Ari Leppäniemi (Finland), Andrew Kirkpatrick (Canada), Yoram Kluger (Israel), Mircea Chirica (France), Marc Maegele (Germany), and many others, became teachers and valuable guides in the project. These links created opportuni­ties for fellowships for Italian doctors, educational programs introducing interna­tionally certied courses, common research programs with the production of collaborative papers. Some of these studies were published in the Journal of Trauma [3–5], the prime showcase for trauma research worldwide. Finally, in August 2015 a decree of the Ministry of Health (DM 2-4-2015 n. 70) formally established the new trauma system on the Italian territory and many hospitals and doctors were immediately available to start with this program.

2.2.1 Trauma System

system was based on the original document of the American College of Surgeon Committee of Trauma (ACS-COT) [6], which at the end of 70s outlined pre-hospital and institutional requirements for optimal care of injured patients, but substantial differences have been introduced: in Italy pre-hospital care of major trauma is mainly led by doctors, especially anesthesiologists, and critical care nurses; trauma hospitals are general hospitals where doctors in the emergency department organize a trauma service and also take care of other emergencies.

2.2.2 Pre-hospital Triage

Since the beginning of the trauma system era in Italy, a signicant number of over­triaged patients (ISS<16) has been recorded (Table2.1). This situation has resulted from the admission to trauma centers of patients with indicators of high energy mechanism but normal vital signs. This is a typical choice of immature systems, where the organization is designed to ensure the maximum protection of the popula­tion. The reliability of these indicators, particularly in road-related accidents, has changed over years because of the development of devices for active and passive protection which can decrease the severity of trauma (Table2.2). For this reason, in the past 2 years a modication of the ACS-COT pre-hospital triage rules has been introduced in Italy, in order to exploit the medical and nursing expertise on the scene. The new triage was inspired by the method used in the Region of the Northern French Alps, where optimal levels of undertriage and overtriage, respectively <10% and 40% [7], have been recorded. Trauma patients are dened triage code 1, if unstable vital signs unresponsive to initial resuscitation are recorded on the scene, triage code 2, when unstable vital signs responsive to initial resuscitation or anat­omy of major injury are observed. Triage code 3 patients have high energy mecha- nism, no altered vital signs and no anatomy of severe injury. The indication of the Ministry of Health is to send code 1 and 2 patients, whenever possible, to a level 1

In Italy, although anesthesiologists and emergency physicians have been most involved in the leadership of trauma care and organization, a new generation of young surgeons with expertise in acute care surgery is growing thanks to the numer­ous educational courses that have recently been implemented by scientic societies (American College of Surgeons, American Association of Surgery for Trauma, Società Italiana di Chirurgia, Associazione Chirurghi Ospedalieri Italiani, Società Italiana di Chirurgia d’Urgenza e del Trauma, World Society of Emergency Surgery, European Society of Trauma and Emergency Surgery), universities and single insti­tutions. The training of an acute care surgeon is a complex process that takes many years. Different steps can be identied (Fig.2.2):

Step 1: General courses on the basic elements of trauma care—such as Advanced

well recognized, both for chest and abdominal injuries [16]. E-FAST should be

performed by one of the trauma team doctors and it is important that everyone

acquires this competency.

Step 3: Courses for surgical training on live animals in damage control techniques

Step 5: Rotation in a high-volume trauma center. This rotation gives the doctor the