Major trauma seems to have become the ‘sepsis’ of prehospital care: with more attention than ever being placed on setting up networks of care, specifically defined responses and considerable resource to get patients to centres of expertise as quickly as possible. It makes sense, and I understand that it’s firmly based on evidence, including the impressively game-changing and solidly learned lessons that came out of the military hospital at Camp Bastion, Afghanistan. The Scottish Ambulance report on major trauma services is available here.
What’s the need?
The main aim is to get those patients with significant injuries – particularly head, internal and polytraumatic injuries – to a centre that can offer immediate cardiothoracic, abdominal, orthopaedic and neurosurgical input, and surrounded by 24/7 radiology, dedicated trauma teams and intensivists. It relies on recognition of serious trauma from the outset, by ambulance call takers and subsequent call interrogation at Ambulance Control. It relies on appropriate trauma teams/paramedic/aeromedical resources being requested. On focussed roadside treatment, but rapid transfer to a ‘Level 4’ major trauma centre. And on an accurate standby call and team configuration being effected at the receiving hospital.
When it works it works well. However, in rural areas it can present particular dilemmas. Helicopters can make transfer to these centres possible from scene, but those of us working in these environments quickly learn that helicopters don’t always fly… or seldom have room for more than one casualty. If you are unable to get immediate transfer of your patient, at what point should you stay at scene, or take your patient back to a community hospital for in-house stabilisation with more light and tools to hand? There is no easy answer: the factors are hugely dynamic.
A recent road accident involving two casualties, that I attended as a BASICS GP responder on Arran, got me thinking and discussing with colleagues who had also been involved. Despite significant injuries, immediate air transfer was not available, and we brought both patients back to our community hospital for further stabilisation and treatment, before transfer later in the evening.
What can we do better?
For some time we’ve wondered if it would be possible to draw up a checklist, or at least some sort of guide to give us ready access to a structured, systematic process of treating major trauma casualties. Despite excellent BASICS Scotland training, and ongoing local refresher training – the fact is that we don’t see these cases very often. A&E forms a frequent part of our rural GP workload, but we probably each see 4-10 cases of serious trauma per year.
We were particularly keen to develop a resource for use at our community hospital. So I asked the question on Twitter:
— David Hogg (@davidrhogg) November 29, 2014
And within hours, responses included the following:
— Kate Dawson (@drceit) November 29, 2014
… as well as this from the ever-helpful Bangor GP/ED superdoc, Linda Dykes (see their website here):
— Linda Dykes (@mmbangor) November 29, 2014
Linda sent me her department’s trauma pathway (and many others, but I’ll leave that to another article!). She is happy for their work to be shared to others who might be able to benefit. As a small community hospital, it’s difficult for us as GPs to find the time and expertise to draw up pathways like this from scratch, so it was hugely appreciated that we had this starting point.
As with our other emergency care work, we were quick to enlist input from our Emergency Medical Retrieval Service. Dr Drew Inglis helped us to make it more specific to our situation, and tie-in with EMRS protocols as they are likely to be involved in the transfer of most of our major trauma patients.
So, keeping in the spirit of the help that Linda first offered us, you can download the PDF version of our major trauma pathway. We’ve had to strip out some ‘sensitive’ contact information, but this can be easily added back in for your own department.
We’re aware that there are likely to be many revisions to follow. We’ll keep this page updated with relevant changes. At some point, we probably need to move from text boxes to tables, and that will help if you have any problems printing the documents below. It will look text-heavy, but this reflects the desire for an aide-memoire to a systematic approach.
However, most importantly, please feel free to share and modify this pathway for your own use. Please let me know if you have found this helpful, and in return I’ll email whenever we have useful changes to make. Thanks again to Linda for allowing all this to germinate in the first place.
For the word document please contact me directly, so we can monitor interest in this. My email address is included at the bottom of the PDF document.