Polytrauma patients who sustain neurotrauma are among the most severely injured patients. Optimizing care of each injury must be prioritized within the context of the fragile nature of the neurologic injuries sustained to ensure that interventions do not create a risk of secondary brain/spinal cord injury.

The combination of neurologic and additional multisystem injury is not uncommon. Recent assessments from the Global War on Terrorism conflicts estimate that traumatic brain injury (TBI) occurs in approximately 60 % of service members who are evaluated for other blunt traumatic injuries [1]. Similar injury mechanisms likely occur in civilian motor vehicle injuries, although the number affected by this combination injury pattern is unknown. Despite the frequency and severity of these injuries, this combination is poorly represented in the literature and further research is needed to address epidemiology, outcomes, and best practices to care for this critically injured population.

Dating back to World War II, medical professionals identified that soldiers were surviving from increasingly complex injuries and living with greater disabilities than could be handled by a single-specialty provider [2, 3]. Therefore, individual providers sought others to collaborate in providing comprehensive care plans that could simultaneously address medical, psychological, and social needs [2]. This initial multidisciplinary concept consisted of a single physician managing and prioritizing the simultaneous input of various specialties [3], and over time this collaborative approach has been shown to improve patient outcomes [4]. Unfortunately, effective multi-specialty collaboration is not seamless. It requires planning, practice, and the commitment of those involved [2]. Specialty providers often practice within single departments with their own unique set of standards, bodies of research, methods of communication, and practice agenda. This isolation creates barriers leading to poor interdepartmental communication which is cited as one of the most common causes of patient care errors [5].

Consequently, healthcare providers have sought to improve multidisciplinary teamwork models to improve efficiency. For a common collaborative disease process, departments are often asked to identify the areas of overlap within their respective disciplines where there are shared elements of knowledge and skills, giving rise to the concept of interdisciplinary teams. For example, in the polytrauma patient, orthopedic surgery and general surgery may both require several operative interventions to complete care [6]. If this is identified early in the patient’s treatment course, these two specialties can coordinate and share operative time thereby decreasing overall nil per os (NPO) status (affecting patient comfort and nutrition) and making the patient more available for treatment by other specialties (i.e., physical therapy, occupational therapy, and speech therapy) [6]. This model requires increased communication , often manifested in interdisciplinary team meetings. However, once interdepartmental trends are identified, care can be facilitated by establishing interdepartmental checklists, management guidelines, or a shared organized approach for rounding thereby reducing overall resource needs and streamlining care.

One example of this is the Brain Trauma Foundation’s (BTF) “Guidelines for the Management of Severe Traumatic Brain Injury ” [7]. In 1995, the BTF recognized that the care of the neurotrauma patient necessitates multiple specialties over the patient’s longitudinal course. In an effort to improve outcomes, a unified, evidence-based approach was designed as an outline to care for the neurotrauma patient [7]. Several studies conducted by Level I and II trauma centers in the United States and Europe, have shown the merit of this collaboration, resulting in improvements in patient mortality, functional outcome scores, hospital length of stay, and overall cost when adherence to specific BTF guidelines have been documented [8–10].

The Brain Injury Guidelines (BIG) project is a recent attempt to develop collaborative practice guidelines. A cohort of acute care surgeons and neurosurgeons identified a population of patients with TBI that could be managed by acute care surgeons without the need for neurosurgical consultation [11]. Both retrospective and prospective validation of BIG have shown no difference in 30-day outcomes; however, targeted research and better allocation of resources have shown a decrease in both ICU and hospital length of stay, as well as an estimated $5,000 savings in hospital cost and $7,000 savings in hospital charges per patient [12, 13].

It has been well-established that polytrauma patients have improved outcomes when evaluation and management occur by physicians within a trauma program that has been verified by the American College of Surgeons Committee on Trauma (ACS COT) [14–16]. The ACS COT has specific requirements for programs to qualify as an ACS verified trauma program [17]. Specifically, the ACS COT requires that in all Level I, II, and III trauma centers “The trauma surgeon must retain responsibility for the patient and coordinate all therapeutic decisions. Many of the daily care requirements can be collaboratively managed by a dedicated ICU team, but the trauma surgeon must be kept informed and concur with major therapeutic and management decisions made by the ICU team.” [17].

With this criteria outlined, the polytrauma patient who sustains neurotrauma should therefore be managed primarily by a trauma surgeon. Recent literature has shown that whether neurotrauma is primarily managed by a neurosurgeon or an acute care/trauma surgeon using discretion to consult a neurosurgeon, the quality of care is similar [12, 13, 18–20]. Furthermore, while neurosurgeons are trained to provide neurotrauma care, their availability as a resource, is becoming increasingly scarce due to shortages in this physician specialty [21, 22]. This fact is even more concerning given the documented increased incidence of patients sustaining neurotrauma [21, 22].

In addition, having the trauma surgeon act as the primary multi-specialty manager for the combined neuro and polytrauma injured patient supports patient/family centered care. A common need identified among patients/caregivers is for consistency of information regarding the plan of care for the day and longitudinally over the hospital course [1]. From the patient/caregiver perspective, it is critical that if several healthcare providers are relaying information, a clear message is communicated consistently [23]. Therefore, it has been recommended that a single provider be assigned to deliver information about treatment plans [24]. Although research is lacking in which discipline is best equipped to perform this task, trauma surgeons may be the most qualified since they already assume the lead role and are integrated in the care of the polytrauma patient throughout the duration of their hospital course.