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Sun Nov 25 00:55:20 GMT 2007

These discussions and the NCEPOD report highlight numerous problems in the UK system which many of us have been aware of for some years. However, there are others issues and I was left somewhat concerned by the reports blinkered views on education. Here I list a breakdown of a number of the key issues from my own personal perspective:

Sadly, throughout the UK there are passionate individuals and pockets of excellence, too small to be a 'trauma centre' who are working alongside colleagues with little if any interest in trauma. May be this is as a result of massive public exposure to the issues of cancer and IHD with little on the issue of trauma, despite it costing our Health Service so much year on year. We need to change this attitude, working with the media!

Courses and education:
Sadly the NCEPOD reports is wholly biased towards ATLS, as if it represents the Holy Grail in trauma education. The previous comments about ATLS failings on this list and the worldwide diversity of trauma courses demonstrates that ATLS is far from ideal. However, it does offer a reproducible, basic system of trauma care which focuses the trauma team on the real issues. Sadly, the course then starts to fail and is far from 'advanced' This inevitably leads to conflict in departments where individuals are more up to date than others, still quoting a life support course written 3 years ago! 
In reality 'which course' is less important than the ensuring an up to date message and regular rehearsal with clinical simulation and  trauma team exercises.

Pre-hospital:
Despite being a small country, pre-hospital care across the UK is hugely variable. In some areas we have specialist advanced trained medical teams, whereas in other we have ambulance services with <50% paramedics and long response times. The involvement of doctors is just as variable with local GP BASICS doctors with limited advanced level skills, but good local knowledge welcomed in some counties whilst advanced level clinicians are rejected by other Ambulance services.  There is often a view that doctors offer little more than paramedics on scene, but this somewhat ignorant view relates to clinical skills rather than clinical judgement and decision making, where doctors may be of greater value. Similarly, many air ambulances in the UK, which are hugely expensive to run, are paramedic only . Such costly resources should be used to maximal effect with advanced trained paramedics and doctors working together.

MERIT teams:
 Due to replace the previously poorly organised and untrained Medical Aid Teams, yet PCTs are reluctant to find funding for training and running of such teams, as there was no Governmental financical support for this idea.

Emergency Department:
Here we are seeing an increasing problem of a developing and advancing pre-hospital world handing over to ER clinicians who are driven by targets and trolley waiting times rather than clinical excellence and advancing practice. There is little point providing advanced level pre-hospital care and effective 'scoop and run' which then stops in the resus room, with the excuse of 'stabilisation' and radiological delays. Any advantage gained or 'window of opportunity' produced in the pre-hospital phase is lost if the drive and sense of urgency is not maintained in hospital getting to theatre or definitive care. 
Yet, there is also a desire to avoid 'trauma calls' because of an impression of disinterest from other hospital specialities when called.

Trauma team:
If called there is often a poor response from disinterested or outdated anaesthetists or surgeons, The latter are often also 'stuck' in theatre and more inlcined to send a junior to the call to see what is happening. This produces further delay. We cannot afford to have a trauma team sat waiting for the 'one big job' but we maybe we could involve more f them in resus/majors to reduce the burden on E Medicine in clearing there department and facilitating access to wards, theatres and critical care.

Radiology:
How many of us have had to regularly argue for CT head scans and then again to include the Cervical spine and more so for other body cavities! The whole trauma team then waits 30-40 minutes for a radiographer to come in from home to start the scanner, which is also outside the Emergency department?!
How many UK hospitals can offer FAST scanning in the ER, something that we teach as a fundamental initial assessment tool on our courses? 
How many Departments could consider embolising a major pelvic bleed during working hours, never mind at night?!
Another hug gap in the chain!

Tertiary centres:
The majority of UK hospitals do not have cardio-thoracic or neuro-surgical services on site. But many of the centres that do offer such capability have developed as totally specialist units and as such have no Emergency Department, general hospital services or direct ambulance access. This then requires a secondary transfer to such a unit, which may have little experience in mananging the other injuries of a polytrauma victim. 
I could go on, but I have already blamed most groups! However, the real issue remains that if there is any 'weak-link' in the chain of trauma care, then all of the excellence that comes before or after is lost and the patient suffers. Trauma centres with direct access from a network of Pre-hospital care specialists may well be the answer but we would need a considerable amount of re-organisation to achieve this from the current situtation, with it's small pockets of excellence, limited by breaks in the chain!

Regards
Mark F
UK

----- Original Message ----
From: "Sise, Mike MD" <Sise.Mike at scrippshealth.org>
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Sent: Friday, 23 November, 2007 3:11:39 PM
Subject: RE: Trauma Care in the UK

The stark reality that the UK has one of the highest ATLS penetration rates in the world and yet has very unacceptable results with survival after injury is bitter evidence of the importance of the presence of a system in improving outcomes. The longer I take trauma call (>20 years), the more I realize that it is not about how much I know, but about how well I work with a wide variety of professional and technical staff to follow practice guidelines and stick to the plan of care. "Old School" surgeons, "Masters of their Universe", make dreadful trauma surgeons in reality. Twenty-five years ago in San Diego, their dominant role in our physician culture made creating a trauma system extremely difficult. Every surgeon fancied him or herself a trauma surgeon and every hospital a trauma center. It took about five to eight years before each of designated trauma centers culled out the "old school" surgeons and other physicians and found those who were willing
 to work within a system of care. "Even a rat learns after awhile", as my wife and colleague, Beth, tells me (often referring to my own behavior). When outcomes are measured, only an organized system can save lives and produce the best results.

If I've learned anything from what I've seen around the US as trauma systems come on line and mature, it is that the UK will have to overcome the "old school" mentality of its surgeons and other physicians. It will be extremely difficult to have outside influences, government included, force change until enough leaders within medicine lead that change. The UK has lead the Western World in just about every major cultural development of the modern age. I'm sure I speak for all of your friends in the US when I say that we hope that you who've come to understand the need for a system of care for the injured can remind your colleagues that it's time to revisit that tradition of innovation and change. 

All the best,
Mike Sise, San Diego
________________________________

From: Jeffrey Hammond [mailto:hammond at umdnj.edu]
Sent: Thu 11/22/2007 9:08 PM
To: Trauma &amp; Critical Care mailing list
Subject: Re: Trauma Care in the UK

I would not be so quick to dismiss this as a failure of knowledge retention. It is a well known principle in medical education that didactic lecture-obtained knowlede has a rapid attrition, and is almost complete at six months, far shorter than the re-certification cycle for ATLS. Unless people are constantly practicing and re-newing the lessons they've learned, the information wuill be lost before it is ingrained. If a student were to take ATLS, and then return to their hospital where they rarely or infrequently see trauma, their performance will degrade to a substandard level over time. 

More simply stated: use it or lose it.

Jeffrey Hammond MD, MPH
New Brunswick, NJ

----- Original Message -----
From: Karim Brohi <karimbrohi at gmail.com>
Date: Thursday, November 22, 2007 6:19 pm
Subject: Re: Trauma Care in the UK
To: "Trauma &amp, Critical Care mailing list" <trauma-list at trauma.org>

> Just to put the record straight I mistated the figures.
> 
> ISS>15:  US: 16% vs UK 30%
> ISS>24:  US: 30% vs UK 46%
> 
> Now apart from the stsem issues, the other thing that is clear form
> the report is that many of the cases of poor clinical care were with
> fundamental ATLS principles.  Now the UK has one of the 
> highest ATLS
> uptakes in the world, with it being pretty much mandatory to progress
> in training in surgery, anaesthesia, emergency medicine etc 
> without it
> from approximately PGY3 onwards.
> 
> So this appears to be either a failure of knowledge retention, which
> is unlikely, but more probable is that it's a failure of
> implementation.  That there is a disconnect between knowing 
> what to do
> and actually doing it.  And I have no doubt that that is 
> not a UK
> problem but a global problem.
> 
> So how do you transition ATLS principles from 'knowing' to 
> 'doing' -
> and how do you do it on a national level?  (This applies to 
> medicaleducation in general, but ATLS is a great starting point 
> as it has
> been so extensively studied)
> 
> Ideas?
> 
> Karim
> 
> On 22/11/2007, Tony Joseph <tjoseph at ihug.com.au> wrote:
> > Karim et al
> >
> > A major issue is that although there are no doubt other health 
> priorities,> traumacare is a  relatively easy one to get 
> right by investing in a few
> > major Trauma centers servicing a defined hub of smaller hospitals.
> > The UK definitely has the expertise but not the mandated 
> organisation.>
> > As a large number of Trauma victims are young, it is also cost 
> effective in
> > treating them right the first time so they can get back to 
> work and be
> > productive.
> > Maybe that is an argument your Government can understand.
> >
> > 43% mortality is pretty convincing something needs to be done 
> urgently?>
> > Also you only have to convince one layer of Government which 
> is a definite
> > advantage?
> >
> > Regards
> > Tony Joseph
> >
> >
> > On 22/11/07 9:48 AM, "Karim Brohi" <karimbrohi at gmail.com> wrote:
> >
> > > Sadly the state of trauma care in the UK is exactly as 
> portrayed in
> > > the NCEPOD report, if not worse.  It depicts clearly 
> the effect of a
> > > lack of a system and lack of any legislated standards of 
> care on the
> > > quality of care delivered to trauma patients, despite this 
> being a
> > > developed country with huge resources.
> > >
> > > I'd recommend the report to anyone involved in trauma care, 
> not only
> > > those in the UK, as the findings have implications for all 
> of us.
> > > This is a unique study in that all hospitals in England and 
> Wales are
> > > mandated to submit data to a NCEPOD enquiry, and this is 
> self-reported
> > > data on nearly 800 severely injured patients presenting a 
> country-wide
> > > detailed snapshot of the delivery of trauma care.  
> Deficiencies in
> > > process of care and their subsequent impact on outcome are 
> relevant to
> > > all of us.
> > >
> > > Anyone in the UK who doesn't recognise these deficiencies is 
> frankly> > blinkered to reality.  2000-2005 outcomes for 
> severe injury (ISS>15):
> > > UK Mortality 43%; US mortality 16% (these are not figures in the
> > > report, this compares UK TARN data to US NTDB data).
> > >
> > > The fault lies not with individual specialties, providers or
> > > hospitals, but with the lack of a appropriately resourced national
> > > trauma system, with legislated standards of care and on-going
> > > monitoring of the health of that system.
> > >
> > > This is the latest in a long litany of reports since the 
> Ormond-Clarke
> > > report first recommended a UK trauma system in 1961.  
> In 2011 it will
> > > be 50 years.  It's about time.
> > >
> > > PDF available: http://213.198.120.192/2007b.htm
> > >
> > > Karim

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