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Trauma Surgery in
Khandahar and Toronto

Homer Tien is a trauma and emergency general surgeon at Sunnybrook Health Sciences Centre who spends half of his clinical time in elective general surgery practice. He serves as an acute care surgeon (1) for one full week six to eight times per year. He is usually able to link this to his trauma call.

Homer spends 40% of his time on clinical epidemiology in two areas: combat casualty research, and civilian trauma research. He is working with Andrew Smith and Fred Brenneman to assure that acute care surgeons are consulted expeditiously - that a patient is seen within 30 minutes of arrival and a decision is made within two hours. Their current goals are to speed up the recognition of surgical problems by the emergency room staff, and to facilitate better access to the operating room despite the competing services that are prevalent in academic settings. Whether decreasing the "door to operating room time" brings about objective improvements is one of the research questions addressed in their prospective clinical database.

The acute care surgeon system has proven to be good for patients and staff. There is more continuous care, more resident interaction, and better life balance for the surgeon. When a general surgeon with a significant practice performs emergency surgery at night, she may be distracted by major elective cases from follow-up care of emergency patients in the ensuing days. Family life is more manageable when the acute care surgeon can predict times of intense and heavy responsibility and match family activities and vacation to predictably lighter periods.

Trauma care is becoming more and more non-operative because of better imaging. 64-slice CT imaging has brought a better understanding of the natural course of solid organ injury. Liver and spleen injuries can be watched without exploration when it is clear that there is no bowel injury. Ultrasound helps determine the need for immediate surgery. It is far better for a patient to go home without a laparotomy after a small splenic injury; late rupture is rare if the patient is observant and wellinformed. Splenorrhaphy is now rarer in adults, but may be more commonly used in children. If the CT shows extravasation or aneurysm and the patient is stable without other visceral injuries, embolization may be the procedure of first resort.

Trauma surgeons prioritize care in the ER, orchestrating the interaction with subspecialties such as orthopaedics, neurosurgery, vascular and thoracic surgery. Most of the thoracic trauma is managed by the trauma surgeons at Sunnybrook, while the thoracic surgeons from Toronto East General provide prompt and excellent backup.

Homer's military practice includes two-month deployment to Khandahar, Afghanistan every 18-24 months. He has served there three times and will go again in October. The spectrum of military injuries is quite different from civilian practice with more penetrating, blast, and burn trauma. The surgery is challenging and there is less subspecialty backup, so emergency neurologic, vascular and plastic operations expand the scope of practice for military surgeons. Care is excellent and the equipment is very good at the Canadian forces hospital. Expectant treatment of splenic injury is replaced by splenectomy if the patient requires air evacuation to the Landstuhl/Ramstein US Army medical center/ hospital in Germany.

Homer's acute care and trauma surgery group is supportive of his military practice. He is now the Canadian forces national practice leader for trauma. Sunnybrook and the University of Toronto receive good publicity for their contribution to the Canadian forces' academic and research activities. Homer now brings military personnel to Sunnybrook to train, and the surgeons from Sunnybrook teach at CFB Borden, the Canadian Forces Base near Barrie. Homer serves as "block leader" for trauma research for the Canadian forces. He has been able to help Sandro Rizoli and his colleagues improve the protocols for hemostasis in trauma, working with a $350 thousand grant for a randomized trial. A larger study in collaboration with US forces is in the planning stage.

Homer grew up in Hamilton and Toronto. He was a biochemistry major at Queen's and then attended McMaster medical school. He is the first in his family to study medicine. He completed a rotating internship at Scarborough General Hospital, then served as a general practitioner in the military for five years - "one of the best times of my life". He learned from participating in a counter-terrorism team, travelling to Yugoslavia, Burma, the Middle East and Tanzania. He learned countermeasures for biological weapons, hostage rescue, how to parachute and dive.

All this adventure preceded his marriage to Vivian during his surgical residency. Vivian has a dental practice is Stouffville, and together they have three daughters, Abigail, 8, Julia, 6, and Evalyn, 2. They live across the street from Sunnybrook. Most of Homer's spare time is spent participating and watching his children in soccer, T-ball and other school related activities. He is currently reading Conn Iggulden's Emperor series, a four-volume historical fiction about the life of Julius Caesar. He particularly enjoyed the Henry V module on Leadership Day. His military experience makes him very appreciative of the surgical training he received in the Gallie program, and in particular, the senior surgical training he received from Tom Gilas at Toronto East General, Bryce Taylor at Toronto General Hospital, and the entire Division of General Surgery at Sunnybrook.


(1) http://www.surgicalspotlight.ca/Article.aspx?ver= Fall_2008&f=AcuteCareSurgeon

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