SURGICAL HISTORY

The contributions of a South African colleague to the evolution and innovation of trauma surgery Chad G. Ball, MD, Andrew J. Nicol, MD, and Pradeep H. Navsaria, MD, Calgary, Alberta, Canada

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he history of trauma surgery is composed of giant leaps forward by iconic surgeons such as Shires, Stone, Mattox, Feliciano, Lucas, Ledgerwood, Fabian, Moore, Demetriades, and Rozycki. These masters represent a true daily ‘‘triple threat’’ of clinician, scientist, and educator. Although these accolades are clearly appropriate and well deserved, we often overlook substantial contributions by non-American clinicians. This is most evident with regard to our South African colleague, Dr. Aaron Stein. Although Dr. Stein received broad surgical training in both England (Whipps Cross Hospital in London) and South Africa (Joannesburg General and Baragwanath Hospitals), his dominant clinical contributions occurred after he was promoted to chief of the Baragwanath Hospital trauma unit in 1962. Given his preceding training by 2 influential preYWorld War II surgeons, he found it especially difficult to follow the traditional dogma of mandatory exploration of all penetrating wounds. This discomfort with nontherapeutic explorations grew concurrently with his experience. He eventually began to practice serial physical examinations in patients without peritonitis, pulsatile hematomas, or hemodynamic instability during his call shifts. This algorithm was eventually buttressed by a retrospective review of his massive institutional case series,

Submitted: June 24, 2013, Accepted: July 19, 2013. From the Department of Surgery (C.G.B.), University of Calgary, Foothills Medical Centre, Calgary, Canada; and University of Cape Town (A.J.N., P.H.N.), Groote Schuur Hospital, Cape Town, South Africa. Address for reprints: Chad G. Ball, MD, University of Calgary, Foothills Medical Centre, 1403, 29th St N.W., Calgary, Alberta, Canada, T2N 2T9; email: [email protected]. DOI: 10.1097/TA.0b013e3182a85f10

followed by conversion to a strict trauma unit policy of selective conservatism.1 Similar to many pioneers, he endured significant criticism upon presenting these findings to his South African colleagues at national conferences. This was particularly vigorous with regard to selective conservatism for penetrating abdominal and neck wounds from wartime surgeons with large experiences in treating patients with high-velocity missile injuries. He received similar friction when he presented algorithms outlining primary colonic repairs (vs. colostomy), avoidance of tube thoracostomy placement in hemopneumothoraces less than 15%, as well as mandatory/urgent exploration of all patients with precordial penetrating wounds and concurrent hemodynamic shock. Dr. Stein’s first major published contribution to the global care of injured patients surrounded this pioneering concept of selective nonoperative management of penetrating abdominal wounds within the modern era.2 This study not only predated Shaftan’s iconic ‘‘selective conservatism’’ publication by more than a year but described a massive, multiyear audit of 646 patients. More specifically, 150 of 340 patients with abdominal stab wounds were managed nonoperatively with only 2 deaths and a 2.4% complication rate. It must be kept in mind that this work was published at a time when surgical dogma demanded mandatory exploration for all anterior abdominal stab wounds. Clearly, this concept has since proven to be safe, reliable, and, in many centers, the standard of care. The next significant original contribution by Dr. Stein came in 1965 when he challenged dominant surgical beliefs by suggesting that perhaps not all thoracic fluid collections required tube thoracostomy following penetrating chest injuries.3 This large, comprehensive series bucked an overwhelming mountain of expert opinion that all hemothoraces required

J Trauma Acute Care Surg Volume 76, Number 1

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drainage on an urgent basis to prevent subsequent restrictive fibrothoraces and complications such as empyema. Dr. Stein’s third major challenge to established algorithms surrounded his group’s extrapolation of selective conservatism to penetrating neck wounds.4 He accurately described both the natural history and the results of a very large group of patients with varying cervical injuries managed via selective nonoperative care. This work preceded similar published experiences from multiple international sites by well more than a decade. While it is clear that the genesis of the massive singlecenter experiences described by Dr. Stein are a direct result of both overwhelming patient volumes and the exponential proliferation of handguns in South Africa, it does not dampen his observations, publications, or pioneering spirit throughout a 30-year career. Although resource-based necessity demanded

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innovative and antidogmatic solutions, propagation of these concepts to the rest of the world mandated insight, courage, vision, and perseverance that should admit him into the rarified and well-deserved company of our other trauma surgical giants.

REFERENCES 1. Clarke DL, Thomson SR, Madiba TE, Muckart DJJ. Selective conservatism in trauma management: A South African contribution. World J Surg. 2005;29:962Y965. 2. Stein A, Lissos I. Selective management of penetrating wounds of the abdomen. J Trauma. 1968;8:1014Y1025. 3. Stein A, Schnier G. Penetrating stab wounds of the chest. S Afr Med J. 1965;39:548Y553. 4. Stein A, Kalk F. Selective conservatism in the management of penetrating wounds of the neck. S Afr Med J. 1974;12:31Y40.

* 2013 Lippincott Williams & Wilkins

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

The contributions of a South African colleague to the evolution and innovation of trauma surgery.

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