 acute care surgery the emergency in surgery so I've named this talk the emergency in surgery and that's really a loaded expression because I want to talk to you about much more than just acute care surgery because acute care surgery is not a standalone new entity it's really part of a rapidly changing landscape in general surgery now there's going to be a talk tomorrow on the birth of acute care surgery so today I thought I'm going to take the opportunity to take a much broader look from a higher altitude look down at this changing landscape now this talk is a mention of topics and issues affecting our surgical community and I think topics that are worthy of your consideration it's really an honor for me to be talking at this conference and I hope you enjoy this talk so this talk is in part of a plenary session on what is new and hot taking surgery to the limits and certainly a QK surgery is new or relatively new depending on what part of the world you are and no one is quite sure where it fits in at least we're not and whether it should exist at all so please take note this talk is really based on our local critters key perspective I'm seeing the world through slightly biased eyes there's nothing I can do about that that's where I work and we have a long way to go locally and Sydney the road has been bumpy it's not being a totally smooth ride and we are addressing some of the issues that I will mention but here we are at as so talking to you about a QK surgeries at least some success in a nutshell so you understand my bias is that locally we do combine a QK surgery and general surgery now I've mentioned the one talk tomorrow but there's also a second talk by myself and I really invite you to come and listen to it where I'm going to take a close-up look at our unit specifically at Khorotyskir hospital now remember it's not as established as colorectal surgery vascular surgery HPB Sydney is not as far as human resources are concerned we don't have guys who have now and women who have now retired and we're just following in their footsteps we certainly don't have the resources as far as finances go for research etc and until recently we really didn't have any data but we starting from scratch it was a blank slate so it's exciting to be part of something like this and these are modern times and we have technology and at least locally we've centered on the use of interactive python and its scientific stack and we can really make use of medium to large data to plan for the care of our patients and equally importantly the education of our new generation of surgeons so again in this talk I really want to just stand back tell you a few things leave you some thoughts and considerations for the future so let's start off by looking at what's happening in the rest of the world I think many countries and institutions have asked themselves are asking themselves will ask themselves you know do we need a QK surgery and if we do what form should it take and I think a QK surgery was really born through a slow realization of its necessity and its necessity because of this changing landscape in general surgery and in some way I think we are reliving the birth of trauma surgery you think back to the 80s you know the the question was asked who was best to take care of this injury to the liver is it their paddock surgeon or is it this new in this new person in trauma surgery that that wants to take care of the liver and today we know what a success trauma surgery has been to isolate these patients to isolate them under the care of certain individuals has really been a phenomenal success so the development of a QK surgery units is really a solution to a problem and I want to concentrate on some of these problems number one I'm going to talk about it many times as this drive to subspecialization and secondly perhaps a decrease in operative trauma surgery so this drive to subspecialization really come about different parts of the world due to duty our restrictions specifically in the first world the loss of operative experience to fellows and other things that I'll mention a bit later the finance lifestyles dedication to a small field in a sense of achievement now internationally a QK surgery is not new there are multiple papers that came out well before 2010 and if you search PubMed you'll find lots of entries lots of returns on the search for QK surgery there's talks on YouTube talks by people like John Ma at conferences he's from I think the northern Northern Carolian chapter of the American College of Surgeons talking about the need the necessity for QK surgery and its development and its growth so many papers on a few search on PubMed let's take a look at one or two of them and what they do is they do highlight the fact that a QK surgery is this solution to a bigger problem facing general surgery and problems to which we perhaps are not not immune so let's look at the UK first of all we have the trainee working group consensus statement on the future of emergency surgery training in the UK from the World Journal of Emergency Surgery now the World Journal of Emergency Surgery is published by the World Society of Emergency Surgery in case you didn't know there's such a society and this is from a working group at the Association of Surgeons and Training Conference in 2015 came out in June this year I think and although it's from a trainee's perspective as to what they feel a training for surgery should be like in the future there are many issues that they do address and I think some of them are worthwhile for us to have a look at first of all is this drive towards subspecialist training now remember the UK is a population density of 413 people per square kilometer and that compares to to the US or 35 and if we crunch the numbers for South Africa it works out about 43 so quite a bit different they really work for all of these people in essence you can put a colorectal vascular HPB in a surgeon in there now this is tongue in cheek Middleburg Metropolis Hospital and to some extent I think we've got to ask yourself are we mimicking those realities around our academic institutions and the big cities that these institutions are and you know should we care about what happens in Middleburg at all secondly they've got much better data than us so they can clearly show that 50% of their missions really are not elective but they are emergencies and the question is who should take care of these patients then all the population with more comorbidities and hypothesis is really that they will do better if they are isolated and you know as we've had the successes in trauma also they've since at least I think 2009 they mentioned they've had more specialist posts being created specifically to deal with this realization that there are emergencies and their question really is with this you know abundance in resources and this population density that they have and they can do something about it their question is should a QK surgery be a subspecialist training in its own right so so that's a step well beyond us we move to the opposite corner of the world we see in a QK surgery can New Zealand afford to wait that's from the New Zealand medical journal and they really two sentences from this paper that I think captures the essence now want to read them to you this is recognizing that it is increasingly difficult to span the knowledge and skill mix necessary to manage all aspects of acute care in general surgery as well as a subspeciality practice the concept of acute surgery has been born so really in the UK where they've got this realisation of all these emergencies they've got the population density they've got the numbers to throw it in the New Zealand perhaps they don't have that and they're asking is it a step too far to ask for subspecialist you know to also take care of acute care in general surgery and the second sentence allowing the current trend towards inadequate numbers and training of surgeons to deliver acute care to continue is really unacceptable so mimicking men many other pay pay papers and all in the mix they mentioned that there's this increase in subspecialization leaving subspecialist inexperienced in acute care there's a decrease in number of surgeons to do after-hour calls certainly a few suspicions of various fields there they are no after-hours calls and people are not willing to do them and perhaps don't feel comfortable in doing them and there's this aging population of truly general surgeons also they mentioned this loss of operative work in trauma that I want to get back to because that gets us back to the US where there has been this explosion in interventional work critical care and the proof standards of living because remember many trauma units internationally rely on interpersonal violence for all their work and and and academic standards etc so certainly we said with a set of trauma surgeons who are perhaps not operating as much as they would like there's also this drive in the use to subspecialization remember they are vast country for its population size so as with us they cannot put a subspecialist in Middleburg Metropolis Hospital every kind of subspecialist so there's a lot of publication and published research from the US and number one this drive to resident subspecialization I mentioned I would get to this a year we go it's lifestyle as different as better perhaps if you subspecialize renumeration depending on how things are funded there's a sense of achievement academic progress and prestige and in reality I mean if you concentrate on one thing we know you do you better you better at that field and that's it's the proper thing to do we're not suggesting any way that that's wrong perhaps more worrying or perhaps the one that we should pay attention to is the surveys that ask residents why they would choose a subspeciality and number one is this lack of confidence after training because of this lack of duty our restrictions and this loss of operative case experience perhaps to two fellows so we're sitting with residents or registrars as we call them that perhaps don't feel that they are ready to to be surgeons so in the United States there's been various solutions to the problems so there are proper tracks in a QK surgery and they different models models that combine a QK surgeon trauma and models that combine a QK surgery with critical care which I think is very important we have to look at our patients are very sick are very are much older and they have more comorbidities and we've got it we've got to consider whether we should do that at all then there's this the outcomes you know it's it's fair all fair and well to suggest that we do that we do all of this but we've got to get look critically at if we if we were to embark on a QK surgery are we gonna have better outcomes so let's let's look at us and not the US specifically no really I don't want to stand here and just share with you or give you my opinion I simply want to mention a few points for consideration for the future of surgical care and and education so we are somewhat behind the times and we need to look at what problems we have in common with the international community and we also need to look at how to go about solving them if they exist and and where the solutions are required at all and if we decide that there are problems and we need to consider you know we need to consider a few things first things first let's realize that not all institutions as I regard the same you know we don't have many training facilities and we serve different communities we in different provinces for instance at Khorotysky hospital we serve the population as both as a primary secondary and tertiary level hospital so we have patients entering a very high cost point which from a financial point of view is certainly not ideal but even though we are all different all our training institutions are different we do share some common goals that we do need to prepare the next generation and we do need to consider the the popular surgical populations care needs on on on a national level and I think to do this and take acute care surgery or surgery as a whole for we need it all starts with data now but South Africa and statistics might start with an S but we certainly know Scandinavian country our data data acquisition really I don't think good enough and if we really want to know what the needs of our population are and the needs of our trainees we need to know about human resources we need to know about the services that we are rendering what the prevalence of diseases are what the outcomes are all sorts of key performance indicators now one of our brilliant young registrars she is doing a doctoral thesis on just getting this data through the country both of public and private she's giving a talk on on the early start of getting that data on Sunday and I really suggest that you go and have a listen to to her work I think it's phenomenally important now some of the examples of the data I think we should concentrate on is is the private sector the funders really need to share the data openly with us we really need to know as educators you know who does what way and how and how you know does the general surgeon do that does not have special suspicious training does he or she do suspicious kind of work does the suspicious to work outside of their subspeciality who does the acute care work and what's the difference between the rural and an urban urban environments and we need that same kind of data from the public sector and I think you'll hear from her talk on on on Sunday that that's really difficult to get we need to critically look at how what our registrars are doing isn't an unpleasant example of a person who phoned me a couple of years ago we've before I got to Cape Town I was in private practice in Johannesburg for many years and critically looking at their rotations as a senior registrar that only done you know five minor cases as a primary surgeon and vascular surgery two mastectomies as a primary surgeon no thyroid dectomies as a primary surgeon three hemicolectomies and what do you advise this person and person where should they go they went to some HPB now do they go to HPB and what if they then went to Middleburg and what if they went to Middleburg straight away what kind of population how do they serve the population so we need to know what is what people are up to and what they do we've perhaps also got a look at the age at which surgeons enter the workforce you know it takes many years to be an intern to do community service to be a medical officer waiting for a job post to be a registrar then to be a junior consultant be a fellow at the end of the day we've got a fairly old surgeon able to cheat but a handful of patients because he or she is so subspecialized we've got approach the subject of foreign trainees it's a wonderful project that we do have but we've we've got a balance set out with with the needs of this country so let's look at some of the data now this is data from the World Bank you can download these data sets they are massive thousands and thousands of entries and rows and columns of data and you've got to use something like interactive Python and the scientific stack to to to work with that data and here's some of the results so we're looking at physicians per thousand patients per thousand people and you look where South Africa language right at the bottom we started off with a country in the 60s like Brazil and look where Brazil has gone more than doubled and we still stuck right at the bottom and if we look at the United States New Zealand America papers from those countries that I've mentioned look where look where they are and that's that for me is really a scary a scary graph and this is our patient is popular populations really exploded in 1995 we're less than 40 million and now we we're heading towards 60 million you know we've got to take care of these people if you look at these big data sets looking at a number of beds per thousand population the entry for South Africa is blank purely because in the public sector we've got no clue and this is the kind of data our doctoral candidates looking at so we've locally we've got this growing population and physician shortage and you know we've got a plan for the future here and up till now I think we've coped but I wonder whether we've coped properly at all because you know in the public sector I think there's a restriction on public health resources so if you restrict the resources then you know you don't need a lot of doctors because there's not a lot of work for them to do and in a private sector there's a bit of magic with numbers and it's a bit of a tongue in cheek thing and I'll get to that in the end so here's our health expenditure per capita you see United States well above everyone everyone else at least in this graph and you see you see New Zealand and United Kingdom in the middle and we languishing right at the bottom as well so we're not spending a lot of money per person here at all if we look at the health expenditure as a whole in the country as a percentage of GDP again we languishing behind countries like the US UK and New Zealand again languishing at the bottom at the bottom of these other countries that I've mentioned there just to be sure on the private side there's a lot more spend but remember this is for smaller subset of patients in the country the larger subset of patients this country is public it depends upon the public health expenditure which is extremely low of course here with the private side you see UK they're down at the bottom because they have private health care sectors quite small now on the private side specifically here we have the consumer price index CPI what we would call inflation rate over the last or since 1990 at least and if we look what the funders pay you for a color cystectomy just a normal color cystectomy you see way back there in 1990s how much you got there about 400 grand odd and you see the CPI you see inflation rate there and what the funders pay you seem to have kept up quite well with the inflation rate but there's something hidden there because this is actually the CPI X and the CPI X is different from inflation rate because it takes out some of the things that you have to pay for every month and one of the biggest what the biggest thing it takes out is your biggest expenditure and that is of course is what you pay for your house so this is from Epsom Bank it starts over there in 1960 what an average house cost and now we up to 1.4 million so 1.4 million really doesn't buy you a very big house but certainly that's the increase in house prices as opposed to the CPI X which hasn't increased dramatically like this but that's one of your monthly expenses so here's a very tongue-in-cheek look at the numbers needed to treat so that's the number of color cystectomy you have to do before your expenses and before your taxes and we see in the 1990s you had to take about about 200 goblets to pay for that very average house now you have to take out almost 600 to pay for that average house so certainly this talk for me is a call to action and because we follow our argument this argument through to conclusion really in South Africa we're gonna end up with no one to take care of the population everyone will be sub-specialized centered around the major major centers will have money only to treat trivial disease and for you in the private sector you'll have to work yourself to death by a very average house what I'm saying is that we really need data and we need advocacy around that data we need to balance to balance our personal needs we as surgeons each of us have our own goals and but there are needs of the population as well we need to consider and needs of our trainees that we have to consider so I'm looking forward to seeing you tomorrow where we take a closer look at what we do at Hridaskir after the talk about the birth of a QK surgery I'll talk about the Hridaskir QK surgery unit and on Sunday please remember the data-gathering efforts of our doctoral candidate thank you