FEATURE TRAUMA MANAGEMENT
the improvement in disease survival to discharge takes in excess of 10 years to bear fruit. The reasons for this improvement in overall survival are determined by a number of aspects. These include the development of inclusive systems, with multi-disciplinary trauma-specific programs incorporating pre-hospital care, emergency room care, early appropriate surgical and orthopaedic care and trauma-focused intensive care. The greatest subsequent advance has been the incorporation of multidisciplinary in- hospital and free-standing rehabilitation services in returning patients to an economically productive environment. The question that remains is how
to develop such systems of care in a cost-efficient and yet outcome-based manner. This short article will attempt to provide an overview of the answer to this question.
DEVELOPING THE SYSTEM Development of a system starts with an understanding of the burden of disease, establishing the need for improved trauma care and getting government health department buy-in to the process. This is particularly important in the light of the World Health Organisation (WHO) Declaration on Emergency Care and the Decade of Action on Road Safety. The next step is training, both of the
prehospital providers and the in-hospital providers. This training can be through formal college- or university-based courses or through so-called short-course training. South Africa has become the first country to formalise trauma surgery as a full sub-speciality accredited by the health authorities. Short courses include: prehospital: PHTLS or ITLS; in-hospital: ATLS® / TNCC® for the emergency room; and advanced courses for the surgical teams such as DSTC™. The training must focus on getting the
patient to the correct level of care within the least amount of time, without delaying definitive operative care, through prolonged resuscitation. The next step is to teach surgical skills, as is taught on the Definitive Surgical Trauma Care (DSTC™) and similar courses, where the operative approach called ‘Damage Control’ and ‘Damage Control Orthopaedics’ is utilised to treat the physiologically unstable patient. The treating healthcare workers need
Arab Health Issue 3 2011 27
«In mature trauma care environments the improvement in disease survival to discharge takes in excess of 10 years to bear fruit»
to understand that trauma patients have more than anatomical injury only; in fact, physiological derangement together with the inflammatory response kills, when prolonged fluid resuscitation is continued and appropriate “abbreviated” surgery is not undertaken expeditiously. This requires that the system include suitable laboratory and imaging services, which may be used for both diagnosis and treatment (e.g. endovascular therapy). Damage Control Surgery has become
the ‘catch-phrase’ of the nineties and today. Originally described by Rotondo and Schwab in 1993 and extended to the bone and soft-tissue injuries by Scalea and Pollack in 2000. The focus is to stop the bleeding, stop potentially infective contamination (source control) and temporise the patient to ‘fight another
day’, then stabilise them physiologically in the Intensive care unit (ICU), with the goal to return to the operation room with a patient in a condition to tolerate reconstructive procedures. The intensive care of the severely
injured patient must be a team effort and the trauma patient has different needs to the non-trauma patient in ICU, including the need for further surgical procedures, haemostatic resuscitation and the provision of prophylactic, rather than therapeutic antimicrobial treatment. The system must ensure that the patient who will require ICU care is transferred to the highest level of care in the system rapidly, preferably through direct transfer. Ideally the surgeons treating the trauma patient should be trained in intensive care and be the ‘captain of the ship’ for the duration of the care of the patient, until stepped down to rehabilitation facilities. The third step in setting up patient-
centred systems of trauma care is the credentialing and accreditation of trauma facilities to set up a network of hospitals that can treat the varied levels of injury severity. The American College
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