The Critical Care Surgeon

While the designation of a specialized hospital site for immediate postoperative care dates back to the early 1940s, the creation of surgical intensive care units with a capacity for days of monitoring and management did not emerge until about two decades later. Prompted by the poliomyelitis epidemic of the 1940s, the demand for effective mechanical ventilation resulted in positive pressure ventilators, which became more widely utilized in these new intensive care settings.

Over the ensuing decades, the initial primacy of airway and breathing support has been equaled by the implementation of monitoring and manipulation of the circulation. This has been accompanied by improvements such as better use of blood products, renal replacement therapy, transplant surgery, emergency cardiac interventions, novel anesthetic agents, new antibiotics, etc (1).

These advancements have prolonged and saved the lives of patients with surgical critical illness, resulting in not only these better outcomes, but also a monumental effort at clinical and experimental investigation to elucidate the fundamental pathophysiology of these disorders and principles of management.

Since the beginning of critical care concepts, surgeons have been actively engaged in patient care, education, leadership, and scholarly pursuits linked to surgical critical illness. By 1987, the American Board of Surgery recognized that surgeons with a special interest and expertise in surgical critical illness should be acknowledged with subspecialty board certification.

Since the 1980s, subspecialization within the context of general surgery has become more prevalent with and without subspecialty board certification, especially in academic medical centers (2). Vascular surgery, surgical oncology, colorectal surgery, and minimally invasive surgery, for instance, have become common arenas of expertise with little or no regular exposure to patients with surgical critical illness.

In contrast, trauma surgery, another common practice of special interest, has maintained an active surgical critical care component with fellowship trainees expected to attain surgical critical care board certification. This special qualification of the trauma surgeon combined with infrequent exposure of other general surgery specialties to surgical critical illness has been a principle underpinning to the creation of yet another specialty—the acute care surgeon.

THE ACUTE CARE SURGEON

The acute care surgeon combines the interests and expertise of the trauma surgeon, the critical care surgeon, and the general surgeon who attends “time-sensitive” surgical conditions. The expectation that many sociological, training, and practice preference features will demand an increasing workforce of acute care surgeons has resulted in the plan for fellowship training in the specialty of acute care surgery (2, 3, 4). Training in surgical critical care is a fundamental component of this new training paradigm, and this manual is designed to assist that training, especially from the perspective that surgical critical illness is, indeed, a surgical condition best understood and manipulated by surgeons.

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