Acute and Critical Care Surgeons at Barnes-Jewish Hospital, a regional referral center for critically ill patients and designated Level I Trauma Center by the State of Missouri, specialize in traumatic injuries, emergency surgeries, geriatric trauma, general surgeries, burn and wound care and critical care. Trainees are exposed to a large, diverse patient population, treating complicated cases on several intensive care units. Research partnerships with governmental agencies, industries and foundations advance patient care and critical care medicine as a whole.
Section of Acute and Critical Care Surgery | 2020 Annual Report
Foot and lower extremity care is an important, often overlooked component of diabetes and peripheral vascular disease treatment. People with these conditions are at high risk of vascular problems in the lower extremities, making it more difficult to treat and heal wounds. Wounds and other lower extremity complications can lead to amputation for many people with diabetes or peripheral vascular disease. The Department of Surgery is developing a team-based care program for the treatment of these patients. Acute and Critical Care Surgery (ACCS) faculty are working in collaboration with vascular and plastic and reconstructive surgeons to coordinate a truly multidisciplinary limb preservation program.
The program began when three chiefs of surgery came together to address a common problem. ACCS Chief Grant Bochicchio, MD, MPH, met with the Chief of Vascular Surgery, Luis Sanchez, MD, and Justin Sacks, MD, MBA, Plastic and Reconstructive Surgery Chief, to discuss the need for a consistent and coordinated effort. Many of these patients receive their initial care from ACCS clinicians after traumatic injury or for extensive wound care. They often require vascular procedures to restore blood flow, and reconstructive surgery to address wounds that will not heal. The need for a multidisciplinary team was clear.
“To my knowledge, this is the first time that three chiefs have come together with this kind of unity and common vision for the treatment of a diagnosis,” says Bochicchio. “We are truly committed to being partners in this treatment, and I think that’s extremely important for our patients.”
ACCS podiatrists Jerry Liddell, DPM, and Michael Weiss, DPM, bring expertise in foot care to the program, while surgeon John Kirby, MD, leads hyperbaric oxygen therapy and wound care for limb preservation patients.
To ensure the success of the program, the three division chiefs are formalizing an algorithm of care with clinical operations staff. Introducing this new algorithm and raising awareness of the program among emergency room faculty and trainees will allow the limb preservation team to provide this patient population the care they need in a timely and consistent manner.
“When a patient hits the emergency room, there will be clear guidelines for how we deliver the care they need,” Bochicchio says. “We want everyone, from residents to faculty, to understand that limb preservation is all hands on deck.”
2020 Highlights
CLINICAL
Since its establishment as a Level II trauma center, Memorial Hospital of Carbondale has brought improved trauma care to southern Illinois. As part of the BJC Collaborative, Memorial Hospital’s trauma center received its Level II designation in 2019. “Prior to our involvement, if you were in a car crash or a victim of gun violence in southern Illinois, your options were limited,” says ACCS Section Chief and acting Trauma Medical Director for Memorial Hospital Grant Bochicchio, MD, MPH. Bochicchio notes that there have been many great saves in the past year and a half. “This is a story about collaboration, extending our reach outside the walls of WashU to save lives in southern Illinois.”
RESEARCH
High blood sugar in critically ill patients, resulting from metabolic and hormonal responses to injury and stress, is associated with poor clinical outcomes, including infections and other complications, increased hospital length of stay and death. Recently, ACCS Section Chief Grant Bochicchio, MD, MPH, presented the findings of his clinical trial using a bedside near-continuous glucose monitor in the surgical intensive care unit (SICU). The first person in this multicenter trial to be attached to the monitor was a patient at Washington University. The device has since received FDA clearance, allowing SICU physicians to monitor blood sugar without waiting for lab results.
EDUCATION
The Surgical Critical Care Fellowship offers multidisciplinary clinical training at the Barnes-Jewish Hospital Level I trauma center in partnership with colleagues from anesthesiology. The fellowship offers training opportunities in the Surgery/Burn/Trauma Intensive Care Unit (ICU), Cardiothoracic ICU, Neurology and Neurosurgery ICU, Medical ICU, Coronary Care Unity and Pediatric ICU. Fellows also have the opportunity to train at Christian Hospital, extending the section’s mission of providing outstanding quality care to disadvantaged and underserved patient populations in North County. “Our focus is on training outstanding physicians with a high level of expertise in caring for the most critically ill patients,” says Fellowship Director Sara Buckman, MD, PharmD.
Acute and critical care research at Washington University School of Medicine in St. Louis, funded by Department of Defense (DOD), has the potential to revolutionize care for the most critically ill and injured patients. ACCS Chief Grant Bochicchio, MD, MPH, the Harry Edison Professor of Surgery, is the Principal Investigator on three key clinical trials.
One in five preventable deaths from trauma occurs because the patient is having difficulty breathing. Typically, EMS professionals use one of two methods to help people breathe: an endotracheal tube or a device called a supraglottic airway, which sits over the windpipe. The Prehospital Airway Control Trial (PACT) aims to compare different ways to help people breathe. Washington University is among a group of centers across the nation participating in PACT, as part of the DOD’s LITES (Linking Investigations in Trauma and Emergency Services) Network.
Patients who are critically ill or have significant injuries can develop acute respiratory distress syndrome (ARDS)—a fatal condition causing severe shortness of breath. ARDS patients are sometimes unable to breathe without ventilator support. ACCS faculty are participating in a national, multicenter DOD clinical trial, Sigh Ventilation to Increase Ventilator-Free Days in Victims of Trauma at Risk for the Acute Respiratory Distress Syndrome (SiVent), which compares introducing “sigh breaths” to usual ventilation of trauma victims at risk of developing ARDS. Sigh breaths are longer and deeper than regular breaths, which may help patients breathe more normally on their own. The study evaluates whether adding sigh breaths to ventilation leads to more ventilator- free days, ICU-free days, fewer complications and lower mortality.
ACCS faculty are also studying new options to address excessive bleeding in trauma. Bleeding
is the most avoidable cause of death in trauma patients, though current treatments for blood loss are sometimes ineffective. The Tranexamic Acid Mechanisms and Pharmacokinetics in Traumatic Injury (TAMPITI) trial at the School of Medicine studied the effects of tranexamic acid (TXA) on the immune system and the body’s ability to absorb and break down the medicine, as well as TXA’s safety and effectiveness in severely injured trauma patients. Researchers are in the process of evaluating study results from the TAMPITI trial, which has the potential to change care for trauma patients suffering blood loss.
By working closely with representatives from government agencies, industries and foundations on research projects, ACCS faculty are committed to improving patient care and making advancements in critical care medicine as a whole.