The field of trauma as a specialty is still relatively young. While care of the injured patient is historically considered the beginning of the entire field of surgery, until recently, trauma surgery has always been just a subset of general surgery. However, with the organization of trauma care both nationally and internationally, trauma surgery has emerged as its own specialty. Successful trauma care requires both dedicated trauma surgeons available on a 24/7 basis, as well as a sufficient volume of trauma patients to maintain competency. With the advent of better imaging techniques (ie: helical CT scans, digital ultrasound) and the application of interventional techniques to the injured patient (i.e. angiographic embolization, endoscopic stenting), the field of trauma has expanded to include both operative and non-operative management of the trauma patient. Due to improvements in prehospital care and the immediate availability of the trauma team for initial resuscitation and management of injuries, most trauma patients that reach the hospital will survive, but many will require prolonged stays in the intensive care unit. Thus, all trauma surgeons must now be comfortable managing critically ill patients.

Research in the field of trauma has focused primarily on the response of the body to injury, attempting to manage the inflammatory response system which, when over-activated can lead to multi-organ failure and death. On the other hand, the compensatory anti-inflamatory regulating system must be controlled or death will occur from overwhelming sepsis. Trauma surgeons are active researchers in basic laboratories describing the response of the body to injury at the cellular level. Outcomes research is also being eagerly pursued by trauma professionals as they attempt to develop management guidelines based on high-quality, clinical studies. On the other end of the spectrum, more and more trauma surgeons are dedicating their time to the field of injury control and prevention.

Training Requirements

Residency

Completion of a general surgery residency is the minimal requirement for working as a trauma surgeon. However, both academic and non-academic trauma surgeons are now opting for at least one year of post-graduate training, primarily in critical care. When choosing a general surgery residency, a student interested in trauma should select a program that includes a broad exposure to organized trauma care, including emergency department training, trauma surgical training, rotations in orthopedic, neurosurgery, and urologic surgery, and surgical critical care.

Fellowship Training

Because trauma surgeons must be competent in surgical critical care, a year of critical care fellowship is essential. Critical care boards cannot be obtained without at least one year of critical care training, and there are restrictions on the number of hours spent during that year that can be used for trauma surgical call (3 months on the trauma service). At the end of a one-year critical care fellowship, and provided that the candidate has already passed general surgical boards, the fellow can sit for the Special Competency exam for Surgical Critical Care.

Trauma Fellowship

Many programs offer a two-year fellowship, one to fulfill the critical care training, and the second for added experience in trauma surgery. (Note: There is currently no separate board for trauma surgery itself). Trauma fellowships are designed to allow the trainee to learn about the various components of running an organized trauma service (i.e.: trauma registry, trauma performance improvement) and to spend time as a junior attending under the guidance of an experienced trauma surgeon. A complete list of RRC Approved Critical Care fellowships can be obtained at the website of the American Association for the Surgery of Trauma (AAST).¹ Trauma fellowship and trauma research opportunities are also listed on that website.

Board Certification

As mentioned above, there are no specific boards for trauma surgery itself. After completion of general surgical boards, a critical care fellowship is recommended so that specialty boards in surgical critical care can be obtained.

Grant Funding, Research Fellowships, Travel Fellowships

Medical Students

Unfortunately, there is little trauma care education for medical students. A few will get a surgical rotation in a busy trauma hospital with a trauma surgeon as a preceptor. Fourth year medical students interested in trauma will often seek out these positions by rotating to another program. Trauma research positions do exist for premedical students at various academic institutions, but there is no central repository containing this information. Even more tragic, medical students are taught almost nothing about injury prevention and control, although there is a move to change the curriculum to accommodate this deficiency. The AAST¹ encourages medical students to attend their annual scientific meeting and selected students will have their expenses covered.

Residents

Residents who wish to pursue careers in trauma surgery should seek out research positions from one of the 10 NIH centers who have trauma training grants. These grants are designed for residents who plan an academic trauma career and are usually for 2 years during mid-residency. Both basic and clinical research are included at most centers. The NIH-Trauma Training Centers are listed on the AAST website.¹

Faculty

Funds for research at the faculty level in trauma are very limited. The American Association for the Surgery of Trauma funds 1-2 trauma research fellows per year, at the junior faculty level. NIH funds for research in trauma are almost non-existent, but the Center for Disease Control for Research and Prevention funds 11 Centers of Excellence in Trauma Care, two of which are directed by surgeons. Additional funds for injury and violence prevention projects for individuals are also available from the CDC.²

Membership in Societies

The American College of Surgeons Committee on Trauma³

Members and Associate members of the American College of Surgeons (FACS) can join their local Chapter's Committee on Trauma. By working with the National COT, the Committees on Trauma assist with designation of trauma centers, organizing trauma systems, education of trauma professionals (including sponsoring the Advanced Trauma Life Support Course), advocating for trauma legislation, and injury prevention activities.

The American Association for the Surgery of Trauma (AAST)¹

This is the largest academic association of trauma surgeons. Their goal is to promote trauma research and dissemination of research findings to the trauma surgical community. Membership requires that the surgeon be a fellow of the ACS and usually has established him/herself in a community as a trauma surgeon for at least 1-2 years after completion of residency/fellowship.

The Eastern Association for the Surgery of Trauma⁴

This is another large group of both academic and community surgeons that holds annual meetings with formal paper presentations. Additionally, they have developed some very active subcommittees that focus on practice guidelines and trauma literature reviews. Their prevention committee has also been very active. The membership tends to be younger than that of the AAST and it is a good place for a junior attending to present her first national scientific paper.

The Western Trauma Association⁵

While being conceived by a bunch of "ski bums" who also like trauma, the WTA is the only trauma group with wide-spread representation from trauma sub-specialists (i.e. orthopedic surgeons, ENT, emergency medicine, neurosurgery, thoracic surgery). The scientific presentations are of high quality and most papers are found acceptable for publication in the Journal of Trauma and Critical Care. The subspecialty involvement is critical in trauma care, and the WTA will only allow 40% of its 125 members to be from any one field of trauma. This is a great meeting for residents, fellows, and junior faculty to attend, but one must be invited by a member. The multi-center study group from WTA has published close to 20 papers and they are heavily cited in the trauma literature.

References

1.                  American Association for the Surgery of Trauma: www.aast.org

2.                  Center for Disease Control and Prevention: www.cdc.gov.ncipc

3.                  Committee on Trauma, American College of Surgeons: www.facs.org

4.                  Eastern Association for the Surgery of Trauma: www.east.org