Current trauma care system and trauma care training in China

Trauma is a life-threatening “modern disease”. The outcomes could only be optimized by cost-efficient and prompt trauma care, which embarks on the improvement of essential capacities and conceptual revolution in addition to the disruptive innovation of the trauma care system. According to experiences from the developed countries, systematic trauma care training is the cornerstone of the generalization and the improvement on the trauma care, such as the Advance Trauma Life Support (ATLS). Currently, the pre-hospital emergency medical services (EMS) has been one of the essential elements of infrastructure of health services in China, which is also fundamental to the trauma care system. Hereby, the China Trauma Care Training (CTCT) with independent intellectual property rights has been initiated and launched by the Chinese Trauma Surgeon Association to extend the up-to-date concepts and techniques in the field of trauma care as well to reinforce the generally well-accepted standardized protocols in the practices. This article reviews the current status of the trauma care system as well as the trauma care training.     

Injury and pre-hospital trauma care in Hanoi, Vietnam

BACKGROUND: In Vietnam, injury is the leading cause of death in children under 18, and road traffic accidents are the fifth leading cause of death. Information systems for pre-hospital trauma care are insufficient. OBJECTIVES: The objective of this study was to assess injury morbidity and mortality, and the existing level of pre-hospital trauma care in Hanoi city. RESEARCH DESIGN AND SUBJECTS: A cross-sectional study was conducted in seven districts in Hanoi in 2006. We studied 2800 households (11,334 members), 9 hospitals and an emergency service centre. RESULTS: The injury morbidity rate was 1134/100,000 (year(-1)), and the injury mortality rate was 23.7/100,000 (year(-1)). There was no significant difference in age or sex between injury severity levels (p>0.05). Road traffic accidents were the leading cause of injury. Causes of injury mortality differed among different age groups. Only 4% of injured cases were transported to hospital by ambulance. Fifty-two percent of victims did not receive first aid at the site. Pre-hospital trauma care was separately provided by the emergency service centre and hospitals. There was no communication network between the emergency service centre and hospitals, ambulances and hospitals, or between different hospitals. CONCLUSIONS: The results reveal that injury is a major health problem in Hanoi and that the pre-hospital care system lacks both coordination and many vital components. Study results may assist decision-makers in identifying interventions to improve health and safety for the population of Hanoi.     

Trauma care systems in France

The French Republic includes approximatively 60 millions inhabitants for almost 550,000 km(2). Prehospital management is organised at department level (96). This management involves a regulatory system initiated from a unique phone number (15 national). The medical regulator sends either first-aid providers or a medical team. On-site care is highly developed and prehospital medically assisted care is really the first phase of the treatment of the injured. The team ensures that the victim is in the best condition for transport and participates in monitoring. Intra-hospital care begins either in an emergency room, with a physician qualified in Emergency Medicine, or in a recovery room, with a surgical intensive-care team. There is no specialisation in trauma in France. All specialist surgeons treat those aspects of trauma pathology that concern them. All surgeons operate on trauma patients and with regard to the organ concerned: digestive, orthopaedic, em leader. The challenge nevertheless remains that of maintaining facilities at a sufficient level to deal with everyday pathology, known for the seriousness of its consequences in both human and financial terms, within an increasingly sparse hospital infrastructure. Suggestions are emerging in response to these preoccupations. Organisation at the European level of hand emergency units (FESUM) is a targeted example.     

Standard of Care for Hand Trauma: Where Should We Be Going?

Emergency Medical Treatment and Active Labor Act, an unfunded mandate for emergency hospital physician coverage, combined with falling reimbursement and escalating medico-legal risk, has resulted in declining enthusiasm for specialty coverage to emergency rooms. In a South West Florida community of 150,000, limited hand surgeons necessitated modification of acute on-call duties for hand trauma, whereby the hospital emergency room personnel performed evaluation and wound management with telephonic consultation followed by referral and definitive care in the outpatient setting by the hand surgeon. The policy for hand care, triage, management, and transfer is reviewed, as well as the first year experience with this highly efficient management methodology for urgent and emergent hand problems. In establishing a county-wide standard of care, emergency rooms and hand surgeons are coordinated to deliver excellent care by treatment protocol.     

Trauma care systems in Japan

The trauma care system in Japan was set up in the 1960s in response to social problems caused by traffic accidents and has since been altered extensively. First-aid and patient transfer are performed by emergency personnel belonging to a fire station. Instead of 'western-style trauma centres', three types of facilities exist: (1) primary emergency care facilities for treating mild cases not requiring hospitalisation; (2) secondary emergency hospitals directed to treating moderately severe disease or injury; (3) tertiary emergency hospitals corresponding to the emergency departments of university hospitals, or lifesaving emergency centres, able to manage the most severe cases such as myocardial infarction, cerebrovascular accident and polytrauma. Although the quantity of emergency facilities and hospitals appears sufficient, the quality of emergency care needs to be improved. This could be accomplished by the unification of small hospitals to create larger hospitals, and/or by the establishment of trauma centres, as well as by improvements in relevant education and training.     

The evolution and current status of emergency medical services for children

Emergency physicians have come to believe that comprehensive pediatric emergency care should be integrated into an overall medical system and organized regionally to address the special needs of children. Since our emergency medical systems have evolved in the care of adult trauma victims, we must look to that development for the origin of our present emergency medical services for children. Not until the 1970s did it became obvious that children, just as adults, should be included in an comprehensive emergency medical system for the care of their life threatening injuries. Since there is considerable overlap in the basic principles of trauma resuscitation and management of shock in children and adults, most children's regional trauma program developed as a part of an overall emergency medical system. The sharing of trauma facilities made it possible to utilize the special expertise of a very small number of pediatric surgeons who had trauma experience and to incorporate their skills into the broader concept of comprehensive regional trauma centers for children and adults. With further experience we soon realized that such emergency medical services for children's systems should include the following components: A two way communication system, a transport system with special equipment for the management of small children, a training program for first responders at the trauma site, a designated pediatric trauma center, a pediatric intensive care unit at the regional trauma center, a neurology/neurosurgery intermediate care unit at the regional center, a pediatric trauma rehabilitation unit and finally a pediatric trauma longterm rehabilitation and management unit for those with residual disabilities. With the further development of this concept of trauma units for children, pediatric surgeons, general surgeons involved in trauma care and pediatric emergency physicians have offered leadership to expand the emergency medical system for children to include life-threatening illness, as well as injuries. Thus, the organization of regional emergency medical services for children permits the highest quality management of children with life-threatening injuries and illness. This then is the final product: an inclusive, comprehensive emergency medical system for children for all life threatening conditions, both trauma and serious illness.     

Regional whole-course trauma care – Experiences from a county-level hospital

Fifty percent of the deaths caused by severe trauma occur within 1 h after injury. With the concepts of “golden 1 h” and “platinum 10 min”, the professionals in the field of emergency trauma treatment have agreed on the necessity of establishing a rapid and efficient trauma rescue system. However, due to the size of the hospital, the population in the neighborhood, the local economic conditions and geographical features, how to establish an optimal trauma rescue system remains an issue. In this paper, we introduced our experiences in a county-level hospital located in middle-and high-income areas.     

Trauma care system in Iran

Objective: The high burden of injuries in Iran necessitates the establishment of a comprehensive trauma care system. The purpose of this paper is to describe the current status of trauma system regarding the components and function. Methods: The current status of trauma system in all components of a trauma system was described through expert panels and semi-structured interviews with trauma specialists and policy makers.Results: Currently, various organizations are involved in prevention, management and rehabilitation of injuries,but an integrative system approach to trauma is rather deficient. There has been ongoing progress in areas of public education through media, traffic regulation reinforcement,hospital care and prehospital services. Meanwhile, there are gaps regarding financing, legislations and education of high risk groups. The issues on education and training standards of the front line medical team and continuing education and evaluation are yet to be addressed. Trauma registry has been piloted in some provinces, but as it needs the well-developed infrastructure (regarding staff, maintenance,financial resources), it is not yet established in our system of trauma care.Conclusions: It seems that one of the problems with trauma care in Iran is lack of coordination among trauma system organizations. Although the clinical management of trauma patients has improved in our country in the recent decade, decreasing the burden of injuries necessitates an organized approach to prevention and management of trauma in the context of a trauma system.     

The Emergency Surgical Team – The Way Forward in Emergency Care?

INTRODUCTION

With reduced working hours and shift patterns, surgical training and continuity of patient care is being put at risk. We have devised a system for managing the emergency surgical patients in an effort to counteract these perceived problems. This study describes the emergency surgical team and audits its activity.

PATIENTS AND METHODS

The emergency surgery team concept is described in detail. Over a 2-week period, general surgical referral data, patient management and operative activity were audited.

RESULTS

A total of 229 patients were referred to the emergency surgical team with 159 treated conservatively, 45 underwent operative intervention and 25 were discharged without admission. Of the emergency surgical team referrals, 58% had gallstone pathology, appendicitis or constipation/non-specific abdominal pain. Average daily number of patients under the care of the emergency surgical team was 26 (range, 10–40).

CONCLUTIONS

The consultant-led emergency surgical team look after many of the acutely sick surgical patients. Our system not only provides good teaching opportunities but ensures optimal continuity of patient care in a busy district general hospital. Such an approach to emergency surgical care has been successfully developed to optimise training opportunities and improve patient care in a setting of reduced working hours and shift systems in our hospital.     

Implementation of an acute care surgery service at an academic trauma center

Background

The establishment of acute care surgery is rapidly becoming a solution to meet emergency surgical needs. Challenges include competition for emergency surgery opportunities and the ability to economically sustain a practice.

Methods

Clinical activity was measured by reviewing the institutional and practice plan databases. Work relative value units and practice plan collection rates defined clinical activity and revenue.

Results

Operative procedures and intensive care unit activity accounted for 52% and 36% of activity, respectively. Although procedures on the digestive tract accounted for half of the operative activity, significant activity was observed in nearly all other systems. Overall clinical productivity remained constant but did demonstrate a 25% increase in operative work relative value units. Current billing activity supports 4.0 clinical full-time equivalents, but estimated collections would cover <73% of physician direct costs.

Conclusions

The authors describe the implementation of an acute care surgery service that combines trauma, emergency general surgery, and surgical critical care in an established academic surgery department. Developing a sustainable economic model must include income sources other than patient service revenue.     

Trauma Management in Australia and the Tyranny of Distance

Major trauma presents a time-critical medical emergency. Successful and expeditious management with early definitive treatment is required to prevent secondary injury. The resources in the prehospital setting, at the hospital of first treatment, and at the tertiary referral (major trauma) center all have an impact on the ability of an integrated trauma system to deliver optimal care to a patient. The time between leaving the injury site and instituting definitive care does not always equate with distance. Retrieval resources must be allocated carefully. Potentially preventable morbidity and mortality has been identified and is specifically related to the time between injury and definitive care and the efficiency of the retrieval and hospital transfer processes. These problems are being addressed with a further sophistication of integrated trauma systems. Regional trauma committees, unified and sophisticated ambulance services, good communication lines, adequate resources at major trauma services, and well developed surgical services are all essential for the appropriate and expeditious management of major trauma patients injured at a distance from tertiary referral (major trauma) centers.     

Trauma/critical care surgery

The specialty of trauma/critical care is relatively new and is currently in a state of evolution as we now face not only a shortage of surgeons but also an alarmingly increasing number of well-trained surgeons who are unwilling to provide emergency care. Regionalization of both trauma and emergency surgical care nationwide is on the horizon and will require major changes in our surgical training programs. However, careers in trauma/critical care and emergency surgery can offer a controlled lifestyle, challenging cases that cross over many disciplines, and a rich field for scientific investigation.     

Does the presence of an emergency physician influence pre-hospital time,pre-hospital interventions and the mortality of severely injured patients? A matched-pair analysis based on the trauma registry of the German Trauma Society (TraumaRegister DGU®)

PurposeThe role of emergency physicians in the pre-hospital management of severely injured patients remains controversial. In Germany and Austria, an emergency physician is present at the scene of an emergency situation or is called to such a scene in order to provide pre-hospital care to severely injured patients in approximately 95% of all cases. By contrast, in the United States and the United Kingdom, paramedics, i.e. non-physician teams, usually provide care to an injured person both at the scene of an incident and en route to an appropriate hospital. We investigated whether physician or non-physician care offers more benefits and what type of on-site care improves outcome.Material and methodsIn a matched-pair analysis using data from the trauma registry of the German Trauma Society, we retrospectively (2002–2011) analysed the pre-hospital management of severely injured patients (ISS ≥16) by physician and non-physician teams. Matching criteria were age, overall injury severity, the presence of relevant injuries to the head, chest, abdomen or extremities, the cause of trauma, the level of consciousness, and the presence of shock.ResultsEach of the two groups, i.e. patients who were attended by an emergency physician and those who received non-physician care, consisted of 1235 subjects.There was no significant difference between the two groups in pre-hospital time (61.1 [SD 28.9] minutes for the physician group and 61.9 [SD 30.9] minutes for non-physician group).Significant differences were found in the number of pre-hospital procedures such as fluid administration, analgosedation and intubation. There was a highly significant difference (p < 0.001) in the number of patients who received no intervention at all applying to 348 patients (28.2%) treated by non-physician teams and to only 31 patients (2.5%) in the physician-treated group.By contrast, there was no significant difference in mortality within the first 24 h and in mortality during hospitalisation.ConclusionThis retrospective analysis does not allow definitive conclusions to be drawn about the optimal model of pre-hospital care. It shows, however, that there was no significant difference in mortality although patients who were attended by non-physician teams received fewer pre-hospital interventions with similar scene times     

Anforderungen an Traumanetzwerke in Niedersachsen

Background

The German Association of Trauma Surgery has developed a concept for the quality-assured care of severely injured patients; this concept includes the establishment of trauma networks. In this study, hospitals and emergency services in Lower Saxony were asked about their demands on the Hanover regional trauma network.

Materials and Methods

Trauma departments in Lower Saxony and adjoining federal states were asked to self-assess their level of trauma care. The demands of emergency services and trauma departments on the trauma network were also ascertained.

Results

Responses to the questionnaire were received from 70.2% of trauma departments and 11.5% of emergency services organizations. Of these, 46.9% of the trauma departments classified themselves as a “center of basic care”, 50.0% as a “regional trauma center”, and 3.1% as a “national trauma center”. Compared with the regional trauma centers, centers of basic care requested fast transfers of patients to a trauma center significantly more often, whereas trauma centers desired more educational activities.

Conclusion

The demands of trauma centers on a trauma network correspond with the aims formulated by the German Association of Trauma Surgery. These demands depend on the level of trauma care provided. Close cooperation with emergency services is essential to strengthen collaboration within the trauma network.     

A strategy to implement and support pre-hospital emergency medical systems in developing,resource-constrained areas of South Africa

Resource-constrained countries are in extreme need of pre-hospital emergency care systems. However, current popular strategies to provide pre-hospital emergency care are inappropriate for and beyond the means of a resource-constrained country, and so new ones are needed—ones that can both function in an under-developed area's particular context and be done with the area's limited resources. In this study, we used a two-location pilot and consensus approach to develop a strategy to implement and support pre-hospital emergency care in one such developing, resource-constrained area: the Western Cape province of South Africa. Local community members are trained to be emergency first aid responders who can provide immediate, on-scene care until a Transporter can take the patient to the hospital. Management of the system is done through local Community Based Organizations, which can adapt the model to their communities as needed to ensure local appropriateness and feasibility. Within a community, the system is implemented in a graduated manner based on available resources, and is designed to not rely on the whole system being implemented first to provide partial function. The University of Cape Town's Division of Emergency Medicine and the Western Cape's provincial METRO EMS intend to follow this model, along with sharing it with other South African provinces.     

Education and training of the future trauma surgeon in acute care surgery: trauma, critical care, and emergency surgery

BACKGROUND: Trauma surgery as a specialty in the United States is at a crossroads. Currently, less than 100 residents per year pursue additional specialty training in trauma and surgical critical care. Many forces have converged to place serious challenges and obstacles to the training of future trauma surgeons. In order for the field to flourish, the training of future trauma surgeons must be modified to compensate for these changes. DATA SOURCES: Recent medical literature regarding the training of trauma surgeons and report of the Future of Trauma Surgery/Trauma Specialization Committee of the American Association for the Surgery of Trauma. CONCLUSIONS: The new post-graduate trauma training fellowship of the future should be built on a foundation of general surgery. The goal of this program will be to train a surgeon with broad expertise in trauma, critical care, and emergency general surgery. This new emphasis on non-trauma emergency surgery required an image change and thus a new name; Acute Care Surgery: Trauma, Critical Care, and Emergency Surgery.     

Multiple casualty incidents: the prehospital role of the anesthesiologist in Europe

The recent increase in incidents involving mass casualties has emphasized the need for a planned and coordinated prehospital emergency medical response, with medical teams on-site to provide advanced trauma life support. The special skills of the anesthesiologist make his/her contribution to prehospital emergency care particularly valuable. The United Kingdom's emergency medical services system is operated paramedically like that in the United States, and is based on rapid evacuation of casualties to hospital emergency medical facilities. In contrast, the French approach is based on the use of its emergency care system SAMU, where both structured dispatching and on-site medical care is provided by physicians, including anesthesiologists. In this article, the lessons learned from multiple casualty incidents in Europe during the past 2 decades are considered from the standpoint of the anesthesiologist.     

Pediatric trauma anesthesia

Trauma has a significant impact on pediatric morbidity and mortality. Depending on the emergency medical services and health care system, anesthesiologists may be involved in pediatric trauma care at the scene, in the emergency department, in the operating room, or in the intensive care unit. Familiarity with the pathophysiology of pediatric trauma and age-dependent anatomical and physiological features is, therefore, essential to every anesthesiologist. Fast and appropriate interventions with respect to the clinical status and the suspected injuries are the key to successful treatment. Due to the high incidence of head injury, airway management and hemodynamic stabilization are of utmost importance. For preclinical trauma care, however, evidence-based data showing a gold standard for pediatric trauma care are still lacking.     

Trauma care systems in The Netherlands

In the late 1980s the Dutch trauma surgeons (Dutch Trauma Society) expressed their concern about the quality of care to the (multi) trauma patients, in the prehospital as well as the in-hospital setting. The following intensive debate with the public health inspectorate and the government became the start point for major improvements in teaching and training (a.o. ATLS), reorganization, regionalization and implementation in which all partners in trauma care were involved. The regionalization of ambulance care, the introduction of mobile medical teams, the availability of trauma helicopters, the categorization of hospitals, the designation of trauma centres, the given responsibility of these centres in the regionalization of trauma care will and already have resulted in an important quality improvement, not only of the individual organizations but for all of the entire chain of trauma care. It has become a major step forward in the philosophy: get the individual trauma patient at the right time at the right hospital. Besides, initiatives have been taken to design a nationwide trauma registration data base in which all in-hospital trauma patients will be included. However serious concerns remain: shortage of intensive care beds, the impossibility to use the helicopter service at night, the shortage in the number of mobile medical teams at night and the slowness in executions of agreements between contracting parties. Many of the remaining problems are a matter of money. Not only (para) medical partners and hospitals but for all government and insurance companies should take their responsibility in this.