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Mon Nov 26 04:47:46 GMT 2007

Mike

The other challenge that now exists in the UK is that there are less and less true "General Surgeons"; the majority of the "Trauma Surgeons" are mainly orthopaedic trained, while the GIT surgeons subspecialise even before they finish what we would know as residency. They qualify not as "General Surgeons", but as one of Breast-Endocrine / Upper GI / Colorectal or Hepato-biliary surgeons. Vascular is also seperate now. This leads to young consultant surgeons who have little idea of the overall patient and the care of trauma in particular. Add to this the lack of a formal ICU requirement in the post-grad training and you see where some of the deficiencies lie.

For this reason we in South Africa are inundated with requests for people to do three month mini-trauma-fellowships to get some experience in General Trauma care.

Regards
Dr T C Hardcastle 
M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA) 
Senior Surgeon / Senior Lecturer: Surgery (Trauma and ICU) 
ATLS  instructor and DSTC Cape Town Course Director 
Intern program Coordinator: Surgery 
M.Med (Emergency Medicine) Executive Committee member 
Clinical Head (Director): Diana Princess of Wales Trauma Unit 
Division of Surgery (General) Room 4064 
Department of Surgical Sciences 
Tygerberg Hospital / University of Stellenbosch 
PO Box 19063 
Tygerberg 7505 
Western Cape 
South Africa 
e-mail: tch at sun.ac.za 
Cell: +27824681615 
Office: +27219389281 or 4911 pager 0302 

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]On Behalf Of Sise, Mike MD
Sent: Friday, November 23, 2007 5:12 PM
To: Trauma &amp; Critical Care mailing list
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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