American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

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Rural Surgery

SRGS Volume 45 Number 7 Rural Surgery CoverVol. 45, No. 7, 2019

Literature Overview
Editor: Lewis M. Flint, MD, FACS
Associate Editors: Scott Coates, MD, FACS; Dorothy Hughes, MHSA, PhD; and Amanda L. Amin, MD, MS, FACS

  • COVID-19 Challenges in Rural Settings 
  • Global Perspectives on Rural Surgery
  • Important Characteristics of Contemporary Rural Surgery
  • Clinical Challenges in Rural Surgery

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Featured Commentary

The online formats of SRGS include access to What You Should Know (WYSK): commentaries on articles published recently in top medical journals. These commentaries, written by practicing surgeons and other medical experts, focus on the strengths and weaknesses of the research, as well as on the articles' contributions in advancing the field of surgery.

Below is a sample of one of the commentaries published in the current edition of WYSK.

Hick JL, Nelson J, Fildes J, Kuhls D, Eastman A, Dries D. Triage, trauma, and today's mass violence events. J Am Coll Surg. 2020;230(2):251-256. doi:10.1016/j.jamcollsurg.2019.10.011

Commentary by: Timothy Park, MD; and Kenji Inaba, MD, FRCSC, FACS

Mass violence events such as the 2017 shooting in Las Vegas can result in a surge of patients that overwhelms hospital capacity.1-4 From the large volume of injured patients, the rapid and accurate identification of those requiring emergent, life-saving surgical intervention is critical. Surgeons can play a pivotal role in providing input necessary for ensuring that their institutions can respond effectively to the unique challenge posed by these events.

Hicks et al. summarize key concepts in mass violence event care with a focus on surgical resource challenges.5 They stress that without engagement in the planning and administrative execution of their center's response to a mass violence event, surgeons may find themselves without the tools or processes needed to help provide the greatest amount of life-saving care under the circumstances of such events.

In the past two decades, there has been considerable nationwide investment in the standardization of an overarching structure coordinating responses to various types of disasters.6-8 This unified scaffolding is known as the National Incident Management System, and the hospital level framework is the Hospital Incident Command System (HICS).9,10 This standardized construct allows for a comprehensive and organized response. It lowers the barrier for communication between levels of response, institutional through local and national, allowing for broader coordination where required. The HICS system is designed around an "all-hazards" approach where a common foundation of response is formed and upon which incident-specific guidance is then laid. Such incident-specific guidance in the context of mass violence events is where surgical expertise is needed to ensure that the right patients get to surgery and that at each step of the continuum, from arrival through post-surgical care, the requisite tools and human resources are available.

The authors emphasize the need to establish a surge capacity of "space, staff, and supplies"11,12as they relate to the surgical care of trauma patients before one's system is stressed by an event. Expanding operating room (OR) capacity urgently and without warning is a tall order at any hospital, necessitating not just space in the ORs but also in holding and recovery, and eventually to the various levels of inpatient disposition. Efficiently managing such a complicated endeavor necessitates an effective central authority as defined by Incident Command in the hospital HICS. In addition to securing reserve sets of surgical tools, having pre-staged and carefully curated groupings of commonly utilized supplies for damage control surgery such as chest tubes, hemostatic agents, and disposables in a known and readily accessible location can significantly reduce the amount of logistical stress placed upon those supporting surgeons during these cases. None of this material will be of any use without appropriately trained and available personnel. A clear understanding of the roles and responsibilities that every team member will need to assume during a mass violence event and a reliable manner to quickly activate additional staff is critical. The authors highlight the financial and logistical complexities of maintaining a stock of staged surgical equipment to accomplish high throughput damage control-type operations and offer several tangible ideas for achieving this goal.

The authors elaborate on the general first steps of a Hospital Incident Command System response, with important considerations ranging from security concerns to training drills. In explicitly addressing triage, the authors define primary, secondary and tertiary triage. They characterize primary triage as the ABCDE assessment occurring on initial patient contact, which helps separate those with minimal injuries from those who require an urgent investment of medical resources to reverse their decline. The authors saliently note that traditional systems of primary triage may occur under triage patients with penetrating trauma,13-15 especially those with "moderate injuries," a higher proportion of which may be found after a mass violence event than after an event where blunt mechanisms predominate. Pragmatic recommendations on triage at the initial point of contact prior to entry into the ED are provided, addressing the nuances of a predominantly penetrating patient cohort.

After this initial triage, they highlight a secondary triage where patients are prioritized for operative/procedural interventions or advanced diagnostics.16 This secondary triage is an especially critical point for surgical input, and having a dedicated triage officer is key to prioritizing care for those patients with correctable life-threatening injuries.3 This person must be able to make these critical surgical decisions, and also understand and manage PACU and critical care resources, and in some circumstances, coordinate transfer to other regional health care facilities.6

Continual reassessment of patients and resource commitments is imperative to optimize patient outcomes by identifying those who require additional interventions while concomitantly balancing duty loads to protect the well-being of the providers involved in clinical and administrative patient care. The authors' term this process tertiary triage, a method that appreciates the dynamism of disaster response.

In sum, the authors underscore the many facets of disaster response and how events with higher incidences of penetrating trauma can stress disaster response systems due to their high operative volume. Surgeons play an integral part not only in the provision of direct patient care, but also in the critical preparation of their systems to respond optimally to these types of events.

It is unfortunate that recent events have highlighted a need for this type of summary document. Nevertheless, mass violence events will likely happen again. Accordingly, for every surgeon in practice, this is a high yield read, with important lessons17 that should be implemented into local disaster plans before the next event occurs.


  1. Lake C. A day like no other: a case study of the Las Vegas mass shooting. Nevada Hosp Assoc. 2018.
  2. Kluger Y, Peleg K, Daniel-Aharonson L, Mayo A. The special injury pattern in terrorist bombings. J Am Coll Surg. 2004;199(6):875-879. doi:10.1016/j.jamcollsurg.2004.09.003
  3. Smith ER, Shapiro G, Sarani B. The profile of wounding in civilian public mass shooting fatalities. J Trauma Acute Care Surg. 2016;81(1):86-91. doi:10.1097/TA.0000000000001031
  4. Peleg K, Aharonson-Daniel L, Stein M, et al. Gunshot and explosion injuries: characteristics, outcomes, and implications for care of terror-related injuries in Israel. Ann Surg. 2004;239(3):311-318. doi:10.1097/
  5. Hick JL, Nelson J, Fildes J, Kuhls D, Eastman A, Dries D. Triage, trauma, and today's mass violence events. J Am Coll Surg. 2020;230(2):251-256. doi:10.1016/j.jamcollsurg.2019.10.011
  6. U.S. Dept. of Health and Human Services. Assistant Secretary for Preparedness and Response. 2017-2022 Health Care Preparedness and Response Capabilities. 2017;(November 2016).
  7. Anderson AI, Compton D, Mason T. Managing in a dangerous world—the national incident management system. EMJ - Eng Manag J. 2004;16(4):3-9. doi:10.1080/10429247.2004.11415260
  8. Board on Health Sciences Policy, Committee on Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations, Institute of Medicine. Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response: Volume 1: Introduction and CSC Framework. (Hanfling D, Altevogt BM, Viswanathan K, Gostin LO, eds.). National Academies Press; 2012.
  9. California Emergency Services Authority. Hospital Incident Command System. Published 2020. Accessed April 26, 2020.
  10. Backer H. Hospital Incident Command System. California Emergency Services Authority; 2014.
  11. Einav S, Hick JL, Hanfling D, et al. Surge capacity logistics: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146:e17S-e43S. doi:10.1378/chest.14-0734
  12. Hick JL, Einav S, Hanfling D, et al. Surge capacity principles: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146:e1S-e16S. doi:10.1378/chest.14-0733
  13. Jacobs LM. Joint committee to create a national policy to enhance survivability from mass casualty shooting events: Hartford consensus II. J Am Coll Surg. 2014;218(3):476-478.e1. doi:10.1016/j.jamcollsurg.2013.11.004
  14. U.S. Dept of Health and Human Services. Assistant Secretary for Preparedness and Response - TRACIE. Mass casualty trauma triage: paradigms and pitfalls. 2019:1-59.
  15. SALT mass casualty triage: concept endorsed by the American College of Emergency Physicians, American College of Surgeons Committee on Trauma, American Trauma Society, National Association of EMS Physicians, National Disaster Life Support Education Consortium, and State and Territorial Injury Prevention Directors Association. Disaster Med Public Health Prep. 2008;2(4):245-246. doi:10.1097/DMP.0b013e31818d191e
  16. American College of Surgeons. n.d. Advanced Trauma Life Support. [Accessed 29 April 2020].
  17. U.S. Dept of Health and Human Services. Assistant Secretary for Preparedness and Response - TRACIE. Mass violence. Published 2020. Accessed April 26, 2020.



Recommended Reading

The editor has carefully selected a group of current, classic, and seminal articles for further study in certain formats of SRGS. The citations below are linked to their abstract on PubMed; free full-text is available where indicated.

SRGS has obtained permission from journal publishers to reprint these articles. Copying and distributing these reprints is a violation of our licensing agreement with these publishers and is strictly prohibited.

Friedmacher F, Puri P. Rectal Suction Biopsy for the Diagnosis of Hirschsprung's Disease: A Systematic Review of Diagnostic Accuracy and Complications. Pediatr Surg Int. 2015;31(9):821-830.

Moghadamyeghaneh Z, Sgroi MD, Chen SL, et al. Risk Factors and Outcomes of Postoperative Ischemic Colitis in Contemporary Open and Endovascular Abdominal Aortic Aneurysm Repair. J Vasc Surg. 2016;63(4):866-872.