Surgical perspective on trauma management
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Discussion on the surgical perspective of advanced trauma management in the UK given to Yorkshire and Humber Intensive Care Network One Day Conference
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Surgical perspective on trauma management
- 1. The Surgeon's perspective Ross Fisher Sheffield Children's Hopsital
- 18. Some people believe football is a matter of life and death. I am very disappointed with that attitude. I can assure you it is much, much more important than that. Bill Shankley
Notas do Editor
- Ladies and Gentlemen, It my pleasure to speak to you today at this conference. I hope you will find what I have to say is of value and I welcome your feedback afterwards about both the content and the nature of the presentation. My name is Ross Fisher and I am the Lead Surgeon for Trauma at Sheffield Children's Hospital. Previously I worked at Leicester Royal and was directly involved in the Regional Trauma Re-Organisation. As part of the British Association of Paediatric Surgeons I was Chair of the Trauma Group from 2008-2011 and was part of the Clinical Advisory Group for the Nation Trauma Re-organisation project so I have a fair handle on the Trauma Re-organisation project. Additionally I am the Chairman of TARNlet, the Trauma Audit and Research Network which analyses data on trauma management across the country so I have a fair handle on some of the numbers involved. So when asked to speak on trauma from a surgeon's perspective I thought that rather than talk about the blood, gore and clever operations I have done I thought it might be helpful, in the context of your network meeting to explain, from THIS surgeon's perspective how Paediatric trauma management and re-organisation will affect us all.
- Trauma is biggest cause of death in childhood 50% of deaths in 1-15 year olds are due to trauma of one type or another, prinicipally RTA. In 2011 there 184 trauma deaths 150 at the scene/before transfer 34 in hospital
- 500 major trauma admissions in the UK in 2011 431 children underwent surgery 265 admitted to ITU/HDU with a mean length of stay of 6.5 days
- Overall survival of these 500 children suffering major trauma is 93% It is within this context that we operate.
- What is clear is that to survive, this cyclist requires the rapid and co-ordinated delivery of the combined efforts of a large, multi-disciplinary team. Out of what often appears only semi-ordered chaos comes a successful outcome in over 93% of major paediatric trauma cases. It may not seem like that to the casual observer but it strikes me that trauma is a team sport.
- The analogy of trauma as a team sport may initially be hard to grasp but I felt it might be interesting to discuss and highlight some of the changes in trauma management around this concept of a team sport, rugby. To some it is just grown men fighting, to other observers there lots of screaming and grunting associated with violence, injury and blood. In fact it might be a trauma room. Indulge me a little A rugby team is made up of 15 players, some huge, some surprisingly small, each with specific individual roles for which they have been selected and positioned. But within the team these roles are often swapped due to the flow of the game with the designated runner being required to tackle and the huge forward finding himself required to run and pass. The success of the team is balanced on the coordination of these individuals to keep the ball from the hands of the opposition and safely deliver it to the try line by any means possible. Let's look at some of the roles and recent changes to their play.
- Anyone with even just a passing interest in rugby knows that the majority of work is done by the forwards and it strikes me this is easily represented by the Emergency Department. Unsung heroes, seldom identified as individuals, working more as teams who take the brunt of the assault from the enemy aiming to stifle their attack and deliver the ball for our team to prosper from. One of the more significant changes in trauma management that the re-organisation will bring around is that major trauma units will see an increased activity as smaller units are formally bypassed. What many previously saw as the hand to hand combat over receipt of major trauma patients is being revolutionised by the development of effective trauma teams to receive, resuscitate and investigate such patients as well as the dramatic increase in specialisation and expertise of staff within units. The continued development of team leadership skills, resuscitation skills as well as targeted investigative skills are essential to the progress of trauma management.
- One constant at virtually every major trauma are the anaesthetists, essential in the onward investigation and movement of the patient. The tongue sticking out is constant too! The advances in understanding of trauma pathophysiology owe a sad debt to civillians and military personnel in Afghanistan and Iraq where so much has been learned at some cost in recent years. One of the most dramatic changes to the prespective on trauma has been a better understanding of damage control resuscitation. The movement away from colloid/crystalloid infusion to massive blood and blood production infusion, targeted management of acute traumatic coagulopathy, permissive hypotension and urgent damage control laparotomy has been clearly shown to improve survival in exsanguinating injuries. And it is these injuries which lead to the majority of deaths. Whilst many in rugby see the sniping annoying scrum half as simply obstructing play it is clear that they are the playmakers facilitating both resuscitation and investigation and the onward movement of the patient.
- The general surgeons. We like to see ourselves as the ball carriers, the real play makers. We certainly look to our big brothers in adult surgery involved in large numbers of life or death surgeries and are in awe, or, more likely, fear. Children are less likely to stabbed or shot than adults but our young adults do like to play grown ups so that remains an issue. What kills most children is blunt abdominal trauma sustained usually as a result of road traffic accidents. The place for urgent splenectomies or hemi-hepatectomies in paediatric surgery is thankfully rare as there is clear evidence of the value in decreased morbidity, mortality and blood use overall in the non operative management of such injuries. The place to manage such injuries is of course the intensive care unit and here we require a close co-operation with our intensive care colleagues. So bear with us whilst we shy away from major laparotomies where we need to pack livers and perform heroics. We've got evidence to back our reluctance! Er conservative management... There does remain a very small subgroup of major trauma patients that will require urgent surgery. Bleeding is what kills salvageable patients. And uncontrollable haemorrhage is what scares us. I really don't “do” blood. I can go a whole operating list and truly spill less blood than the anaesthetists. So faced with uncontrolled haemorrhage I'm not happy. One of the reasons alluded to above is that we just don't see such in our training. So I went off and got myself a bit better trained by doing the Definitive Surgical Trauma Skills course where I learned an awful lot. The essential in uncontrolled bleeding is NOT replacing blood with clear fluid, NOT wondering which investigation to carry out and NOT standing around wondering whether to operate or not but to “Get in, quick, stop the bleeding and get out.” It ain't pretty and it certainly isn't minimally invasive but it is the only way to stop the problem. And here we will often “phone a friend” to come help. The essential of the damage control laparotomy is precisely that, not an opportunity to fix everything but merely to assess the damage, stop the bleeding and GET OUT to allow you guys to fight the trauma triad of hypovolaemia, hypothermia and hypocoagulopathy. Teamwork.
- Neurosurgery. Head injuries occurred in 79% of major paediatric trauma victims, was the cause of death in over half of in-hospital fatalities but only 17% of trauma victims underwent neurosurgery. The aim of management of closed head injuries is to prevent secondary damage and requires ventilation to normocapnia and urgent correction of hypovolaemia and hypotension. In this can be seen conflict with the proposed permissive hypotension approach for exsanguination and here the multi-disciplinary “team” approach to multi-system disorders is essential understanding that permissive hypotension is not a treatment goal but a necessary evil to be overcome as soon as possible by a damage control laparotomy.
- The orthopods, bless them. The constant butt of everyone's jokes but we couldn't do without them. Whilst we are happy to leave them to straighten out the fractures it is important to remember that exsanguinating haemorrhage from pelvic fractures are a potentially fatal injury. The development of easily applied pelvic binders has superseded the need for complex external fixators. Rather than dismiss the 'pods in acute trauma management it is useful to consider the fact that a team is made of members who whilst they have specific titles should be able to take on any of the roles required. Whilst Martin Castrogiovanni is clearly not built for lightening pace there are many who tremble at the sight of 120kg of man mountain in full flight with the ball under his arm. Increasingly in trauma care the boundaries between specialities are blurring as the Trauma Surgeon develops, a ultilitarian, defined in one field but with experience and expertise in many. In the future I hope the role of specialist trauma physician will emerge as some scary hybrid of all the previously mentioned specialities.
- ITU. So that's you lot? What can I say? Delicate pretty boys who come in once all the hard graft is done and scoop the glory, avoiding the carnage whilst everyone stands and watches unable to do anything? Harsh. And unfair. I don't have to tell you guys how trauma management has moved forward, how there is an increased burden of increasingly sick patients. Maybe what I should tell you is actually how much we all value what we do. The scariest thing ever said to me, in a previous hospital, when I asked for help from ITU, was “no”. Long story, and I eventually got the help I needed. We recognise that enormity of what you have to cope with as the trauma triad takes a hold and no-one else, save the prayers of the righteous, can do anything. we recognise how you pull patients back from beyond the precipice and offer hope when we think all hope is lost. We recognise that often it is you who are the most supportive and realistic with the families and you who draw back the multiple teams to ensure that the holistic nature of patient care, not just liver haematoma or lung contusion is managed. Thank you, you're doing a great job. Let's continue to work together as a team on this shall we?
- This is one of the “back rooms” at Murrayfield. I highlight this because it would be arrogant and naïve to believe that we have covered all the major players involved in the delivery of advanced trauma care. Some may not wear numbers on their back or even appear pitchside but are an essential part of the team striving for success. whether that be radiology, physiotherapy, theatre staff, dietetics, pharmacy, occupational therapy and rehab, speech and language or the ward auxilliary. there are untold numbers without whose essential and developing input we would fail. It is important that as we develop our trauma networks to quantify and include the input of the backroom staff.
- It may look like we are back to the forwards again but in this slide I wanted to highlight the change in practice that the trauma re-organisation will bring about in terms of patient transfer. Previously non specialised crews were detailed to “scoop and run” from incidents but more and more, as alluded to by Chris will there be specialised teams made up of highly trained paramedics and medical staff attending the scenes of major trauma and beginning the delivery of care both at site and during the transfer. Thus the blurring of roles of ED staff and transfer staff. Additionally transfer of the major trauma patient is no longer to the nearest casualty dept but to the definitive care facility of a Major Trauma Unit. As such we can consider Embrace as part of our forwards group as the transfer itself will not simply be an ambulance ride but part of the definitive care strategy. The communication and co-ordination to achieve this is being developed whilst protocols are established. The outcomes for patients will be audited and developed as part of trauma networks.
- Which brings us to the suits. Nothing in medicine happens without people in suits and increasingly the ONLY people wearing suits are managers. The rest of us are naked. From the elbow down. The role of managers and commissioners in trauma management is important yet they are powerless once the team cross the white line as poor Martin Johnson learnt to his cost. The effective provision of resources, the support of data collation and audit, the integration of care pathways often across previous geographic boundaries, the attention to funding following the patient, the support and development of education, ALL are roles that are essential as the trauma networks are established and developed. Clinicians sometimes believe it all starts and ends with them but without effective engagement with the suits, trauma care will never reach its fullest potential.
- Lastly, there are the supporters. Any sportsman, Olympians most recently, will tell you of the amazing effects of a partisan crowd. In trauma management, as a sport analogy I think the supporters are analogous to the smaller hospitals within the network, those without major Trauma unit designation; the Trauma Units and Local Emergency Hospitals. Whilst the intention is that the major trauma cases will be routed to bypass these smaller units there are two issues that will still require some trauma care to be delivered in the periphery. The first is a concerning statistic from the TARNlet database that shows that TEN % of children with major trauma were delivered to ED not by ambulance but by “other means”. In other words parents and carers are performing the “scoop and run” rather than waiting for advance care to arrive. As such, at least in the short term such units will still be receiving major trauma. Secondly, there is provision built into the guidelines that, if during a transfer and bypass, it is perceived that advanced care such as intubation is required, an ambulance may stop at a TU or LEH. Where previously the casualty would have then been admitted and initial care commenced it is envisioned that this care would be provided at the front door and the journey continued immediately. As such it can be seen that whilst peripheral hospitals will continue to have a supportive and rehabilitation role they may occasionally be required to step up into a more delivery role in the management of stabilising and transferring patients.
- Which brings us to this. The pinnacle of sporting achievement if you are English. I'm Scottish. But as analogies go, this moment with Jonny Wilkinson kicking a drop goal to win the 2003 Rugby World Cup sums up the analogy of trauma as a team sport. With seconds to go and the match even the forwards had lumbered up the pitch to get within drop kick range, they channelled the ball back to the scrum half Matt Dawson who supplied Wilkinson who scored the winning point. It wasn't pretty and it wasn't orthodox, but England won. And so it is with trauma management- the coming together of a multi-disciplinary team, each playing their part to achieve victory.
- Here's a wise man speaking about his view of a team sport. I think the analogy continues to work. Some people believe trauma management is a matter of life and death. It is, but I'm very disappointed with that attitude. I can assure you it is much MUCH more important than that.
- I like to think that this slide answers one of life's great questions, are there any others?