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Mon Aug 20 17:44:17 BST 2007

I have read with interest the postings over the last 24 hours regarding 
the trauma case in Boston. This is unfortunately an ever-recurring 
problem as a result of hospitals that are driven wholly by targets (which 
is going to be even more of a problem here in the UK with PBR [Payment By 
Results]) where hospitals bill Primary Care for every investigation/ 
intervention as separate procedures! I am informed that £2.87 (approx 
$5.70) is now billed for every venepuncture and £15.32 (approx $30) for a 
PR exam! There is an obsession with numbers. Where has patient-centred 
healthcare gone?

There is already the majority (thankfully not exclusive!) mindset in some 
surgical arenas in the UK where trauma surgery "does not exist" let alone 
there being any requirement or patient demand for such a speciality?! So 
where is the motivation for treating these trauma patients coming from? 
(apart from those of us on this list and elsewhere with an interest in 
trauma and in reducing morbidity and mortality from the same)

I recently had a "heated" debate with a group of surgical colleagues when 
I quoted several citations regarding trauma being the greatest cause of 
morbidity and mortality in the economically active age-groups (more so 
than IHD, Cancer etc. combined.) They were astounded at this fact (which 
perturbed me greatly.) They went on to refute this but without any proper 
evidence or logical counter-argument. I accept that this is not a 
representative sample of the world's surgeons and that opinions and 
values vary from country to country depending on the various factors 
involved (as always!) such as motivation, economics, politics, legal, 
ethical and social issues etc.

Therefore, it is clear to me that for a trauma patient to receive the 
best care possible "Gold Standard" he/she needs to receive care by a 
clinical TEAM interested and motivated with the necessary skills and 
experience in trauma management who understands the latest evidence-based 
medicine. This includes surgeons, anaesthetists, intensivists, ED 
physicians, radiologists (whether clinical or interventional), theatre 
teams, nurses and paramedics etc. It most certainly is a MULTI-
DISCIPLINARY TEAM of all specialites/backgrounds etc.

The care needs to be expeditious, of the highest standard, and the aim of 
ALWAYS acting in the patient's best interests. Unfortunately, a breakdown 
in this system anywhere along the patient's journey detracts from such 
high quality care.

The utopic patient journey (whatever that is?!):-

- Diamond 5 (life-preserving 5 minutes at scene from time of injury - 
with rapid transfer to hospital);
- Platinum 10 (time from injury to hospital arrival);
- Short stay in the ED - bypass through merely for patient hospital 
registration (allow 15-30 secs :) );
- Transfer to operating theatre/interventional theatre (if UNSTABLE) OR
  Transfer to CT scanner, ITU/HDU or ward (IF STABLE)
  (All above with Golden Hour);

In theatre (UNSTABLE) - Damage Control Surgery (RAPID) to achieve:-

     1) Rapid surgical control of haemorrhage (cross-clamping, shunts, 
ligatures, abdominal packs etc.);
     2) Ensure adequate prevention of sepsis; and,
     3) Prevent multi organ failure

then (as for STABLE management) rapid transfer to ITU etc. for correction 
of:-

     1) Metabolic Acidosis;
     2) Coagulopathy; and,
     3) Hypothermia

using whatever organ support necessary to achieve this.

Employing throughout such principles as:-

1- permissive hypotension,
2- TRANSFUSING 1:1 (PRCs to FFP etc. with appropriate clotting factors - 
as per massive transfusion protocol) IN THEATRE AND AFTERWARDS in the ICU,
3- AVOIDING the use of pressors with uncontrolled hypovolaemia,
4- CONTINUE agressive rewarming etc.
...to name but a few!

Take back to theatre within 24/48 hours for rewashout, definitive surgery 
etc. with a "controlled" non-acidotic, non-coagulopathic, non-septic 
patient (at least hopefully!!)

I understand that this is a "model" outcome and nothing fits such a 
picture so easily (ESPECIALLY with all the many potential pitfalls along 
the way starting at the roadside [with difficult prolonged extrication 
etc.])...but isn't that what we should all aim for at least?!

Am I missing something or have I completely lost the plot?? I am more 
than happy to be "educated", "preached to" and have my 
practices "changed" by the endless list of experts on this forum.

I wonder if the numerous cases of mis-managed trauma cases that I not 
only hear about (as in the Boston case), but also repeatedly bear witness 
to, are a result of lack of motivation in trauma care, knowledge or 
skills? (maybe even a combination of all 3!) I am however convinced that 
the lack of motivation is the root cause analysis of these failures. Does 
anyone agree?

It is time that things changed and a concerted group of like-minded 
individuals are (I believe) the only effective means to educate and 
implement this change that is not possible any other way; as indeed 
started some years ago now and has been going on ever since.....oh yes, 
come to think about it....it is this list!

I would be pleased to receive people's opinions (either on or off list).

Regards,

Matthew R
Surgery UK

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