From a strategic standpoint, most hospitals, even those with the most unfavorable patient payer mixes, find trauma care to be a profitable service. Trauma surgeons are not always well reimbursed for their care, but the hospital where the care occurs usually makes a reasonable margin on each admission. The trauma director can use this fact to his or her advantage in negotiating issues with administrators. In terms of the theory of the trauma business, the strategy becomes: “The trauma surgeons will provide 34 h, yearlong coverage of this profitable service line, coordinating disparate services, managing the details of patient care and placement.” This service may require either a subsidy from the institution or, more effectively, access to alternative practice zones such as critical care or emergency surgery.

Most trauma directors will find that there are insufficient RVUs available taking care of trauma patients alone to balance the books. It is this reality that has led a revolution in trauma care. Many trauma services now expand their focus to include non-trauma patients: the acute care surgery model. The acute care surgery service, in addition to managing all the trauma admissions to the institution, also manages traditional general surgery emergencies such as bowel obstruction or appendicitis, i.e., any abdominal visceral inflammation, obstruction, or perforation fall under the preview of the “Trauma and Acute Care Surgeon” [7]. Surgical critical care can be an important component of this model as well. Since many of the patients in the surgical ICU “belong” to the trauma service anyway, it makes good sense from both a patient care and a financial standpoint for the trauma service to manage these cases. Many trauma/acute care surgery programs find it advantageous to perform as much of the procedural work their patients need as possible, including procedures such as percutaneous gastrostomy and IVC filter placement, which may, in many institutions, “belong” to others.

To accomplish the tactical missions outlined above, the trauma acute care surgeon must not only be an expert visceral surgeon but also must be a skilled, fellowship trained, intensivist. He or she must also maintain the procedural skill necessary to perform all the procedures on the menu the director establishes. It is better to eschew procedures one cannot master. In fact there is some evidence of a learning curve in services adopting the acute care paradigm.

In addition to clinical excellence, the trauma acute care service must establish impeccable and focused business practices. To maximize the team’s profitability, and therefore its viability, all clinical activity must be accurately documented and appropriately billed. This usually requires the addition of skilled, nonphysician team members. Physician extenders such as physician’s assistants and nurse practitioners, carefully deployed, can multiply the work throughput of the trauma acute care surgeon. In addition, a business manager to attend to the details of coding and billing is essential for efficient charge capture and compliance with billing regulations.

An approach to trauma care involving the addition of acute care surgery and critical care medicine can provide a “balanced portfolio” providing patients with excellent, team-oriented continuity of care while providing surgeons with a challenging and profitable work environment. Creating such a balanced portfolio may be the key to success for trauma center directors and their administrative champions.