Sunday, 7 February 2010

A couple of old chestnuts 001 - trauma survival in the UK.

The BBC and ITV news networks here in the UK have very little real news to report and so have raked over a few old medical coals in the hope of shedding some light in the otherwise foggy and cloudy UK at present where large numbers of drivers seem to think that headlights are passé in such conditions.

We here at ND Central think that there is nothing new in this story as a few decades ago those of us that were junior surgeons, both general and orthopaedics, and those of us who were anaesthetists all encountered the same problems. When there was major trauma there was no-one senior around.

The more educated of us knew of things that improved survival after trauma for example skilled paramedic care, rapid transportation from trauma scene to a site where specialised care was available and the so called golden hour. Such things we learned from our seniors especially those who had worked in the military and in the States. We learned too from watching American TV programs as M*A*S*H and Quincy M.D. and comparing them with our NHS and American textbooks found in better University libraries.

Today senior medical staff watch ER to keep up to date with the first world and weep.

We remember going to meetings with the consultants from A&E, anaesthetics, orthopaedic and general surgery to discuss how bad trauma care was and asking to be sent on ATLS (Advanced Trauma Life Support) courses.

The consultants, who were never there in the middle of the night, listened to our arguments and concluded that rather than allow the frontline staff study leave to do these courses, they would themselves go on these courses and relay down their knowledge while still sleeping in their beds when something serious happened and delaying authorization for urgent CT scans for head injuries.

Now there are big differences between the USA and the UK which were not pointed out in the BBC News item. We recall going to a lecture on gunshot injuries by an American surgeon from Texas who started by asking how many gunshot injuries did we get a year at our hospital?

The A&E consultants said one, maybe two in a busy year, and these were usually accidental discharges of shotguns by farmers going over styles with unbroken shotguns and one too many stirrup cups on board.

The surgeon from Texas could not believe what he was hearing for he said they had at least 2-3 stabbings a night usually early in the evening and later there were 2-3 shootings a night.

So perhaps one reason we are not good at treating trauma is that we live in a relatively “safe” country? An argument perhaps, but medical training should encompass the “what if?” element, and allow a degree of preparation for it even if it happens rarely.

Compare the standards of training for trauma. A good friend who currently works in the USA met one of us after a year into an orthopaedic training program. At that time one of us had done a year of orthopaedic surgery in the UK a good few decades ago now and, as doctors do we compared notes.

The amount of serious injuries they had seen made us look like rank amateurs. This was mainly due to the effects of crack cocaine and alcohol combined with the ready availability of firearms and motor vehicles rather than the huge availability of demented old ladies breaking hips and wrists.

It is said that if you wish to learn surgery go to war and certainly some of the injuries they had seen in crack houses where the inhabitants let rip with pump action shotguns causing multiple compound femur fractures at a time compared with the odd 3 or 4 closed femoral fractures (in ones) we had seen in the UK usually from road traffic accidents.

We compared our training. Before our friend could start their first medical job in the States they had had to do both the ATLS course and an advanced resuscitation program as well. We had a resuscitation officer teach us ours a nurse and maybe after 2-3 years into our post graduate medical training we might be honoured with study leave to go on one of these courses.

So perhaps the Americans are better at trauma than us for several reasons like being at least 20 years ahead, having better “basic” training and, last but not least, having more guns and smack heads with ready access to cheaper alcohol and petrol.

Now we do not advocate the introduction of the last few items but better training and trying to keep up with “modern” medicine are not huge items of expenditure but they could reap rewards. Unfortunately, this specialist training is time consuming and so it means taking junior doctors away from their “service” role which might mean missing waiting time targets while a few more trauma deaths is not a target yet.

As a result the NHS is still stuck in the meeting we had with the consultants a few decades ago. If it does not impact on anyone senior in NHS consultant or manager land it is not there.

Patients will continue to die from minor stab injuries because poorly trained surgeons cannot resect a liver lobe that is bleeding. Patients will continue to take five hours with multiple limb fractures and internal organ damage to travel 400 yards to an operating theatre to stabilise their injuries because of hospital bureaucracy and then develop life threatening complications as a result of unfixed fractures.

Lots and lots of NHS targets but nothing much has changed.

In GP land we have to do a mandatory resuscitation course once a year. It is a joke.

One of or staff showed us the latest “new” weapon in resuscitation. It looked suspiciously like a laryngeal mask that one of our number had used regularly as an anaesthetist 20 years ago. The trainer showing off this “new” equipment was a paramedic whom we had been involved in training when we were anaesthetists several years after other parts of the UK had introduced paramedics but remember this is the North.

This is not progress or proper training it is box ticking to show that we are being “trained” (badly).

We are still waiting for the same basic training that American junior doctors get before they can even start working. And this is several decades later.

Praise be to the Party for ensuring that all of us doctors are up to date. Trauma care has not changed much from what it was 20 years ago. We were behind then and things have not changed much since. The knowledge is there the implementation and application of it is not.


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