"24/7 consultant led trauma teams produce the best outcomes"
The Debate - Tony Smith
Outline
24/7 Consultant led trauma teams do not produce better outcomes
Tony Smith
Intensive Care Medicine Specialist, Auckland City Hospital
Medical Advisor, St John Ambulance, Northern Region
Consultant led trauma teams
• Take a look at the evidence
– There is no good evidence supporting consultant led trauma teams
– Discuss the level of evidence available
• The evidence supports factors other than trauma team leader having a large part to play in determining outcome
• Most trauma interventions can be performed by registrars
– Trauma calls are an important part of training
• It isn’t practical, or economical, to have consultant led trauma teams
• Conclusion – 24/7 consultant led trauma teams do not produce better outcomes
Surgical consultants and trauma
• Specialist trauma surgeons do not exist in New Zealand
• The general surgeon is almost extinct, sub-specialisation is increasingly the norm
– Hepatobiliary surgeon
– Head and neck surgeon
– Breast surgeon
– Vascular surgeon
– Colo-rectal surgeon
Trauma is increasingly a non-surgical disease
• Most trauma patients do not need surgery
– DPL has been replaced by FAST
– Other resuscitation procedures do not need a surgeon
– CT imaging has replaced surgical decision making
– CT imaging increasingly results in non-operative approach
• When a patient requires surgery it is usually obvious and it does not require a surgeon to make the decision
• In blunt trauma, the most common form of emergency surgery is neurosurgery
• What about the evidence?
Surgeon as part of trauma team #1
• Retrospective, trauma database, six months
• Compared trauma calls that had surgeon either present or not present
– No difference in any outcomes
– Shorter time to the OR, particularly for penetrating trauma
Surgeon as part of trauma team #2
• Comparative study of two trauma centres
– One with surgeon in hospital (IH)
– One with surgeon out of hospital (OH)
– 21 month period
• Results
– Time to OR was shorter in IH group for penetrating trauma, but not for blunt trauma
– No difference in mortality
Surgeon as part of trauma team #3
• Retrospective review
– 16 months (1043 patients)
– 4 surgeons, 2 in hospital (IH) and 2 out of hospital (OH)
• Results
– Time to OR shorter in IH group
– No difference in mortality or hospital length of stay
• A number of other similar studies
– The presence of a surgical consultant does not improve outcomes
Emergency medicine consultants and trauma
• There are a number of studies that have looked at outcomes before and after increasing the numbers of emergency medicine consultants
• Conflicting results
What about emergency medicine consultants?
• A number of other similar studies
– Conflicting results
• In all studies there were confounding factors
– Trauma system was set up at the same time
– Impossible to separate out the effect of emergency medicine consultants
– Most studies concluded that the trauma system was the biggest factor in improving outcomes
What about anaesthesia consultants?
• There are no studies
• They are far too busy to come to the ED
– Is this true?
The truth…
• They can’t go anywhere without a huge pile of equipment and a technician to hold their hand…
What about intensive care medicine consultants?
• There are no studies
• They are far too busy saving lives and taking phone calls to leave the ICU…
– Is this true?
The truth…
• It is really hard to read the paper and drink coffee if you are leading a trauma team…
How good is all of this evidence?
The Smith modification
• Level one – randomised trials that support my own opinion
• Level two – expert opinions that support my own opinion
• Level three – all other forms of evidence that support my own opinion
• Level four – any form of evidence that does not support my own opinion
• Level five – the uninformed opinion of morons
The uninformed opinion of morons
Is there any other evidence?
• Mortality rates for major trauma typically 15-20% for hospitals with predominantly consultant led trauma teams
• I have uncovered new research data that shows that far more impressive outcomes can be achieved without consultants
Chicago Hope trauma mortality 10%
ER trauma mortality 5%
Baywatch trauma mortality 0%
There is a clear trend…
• Dug deeper into the data from these studies
– It was clear that there was a trend
• Multi-logistic regression analysis reveals that there is one over-riding factor responsible for the difference in these mortality rates
• This research is groundbreaking
– First to hear these results
It is all about breast size…
• It has nothing to do with consultants
• It is all to do with breast size
– Healthcare workers with larger breasts
produce lower mortality rates
• We do not need to employ more
consultants, we need to employ
staff with larger breasts
• Targeted ACC funding
• Priority for DHBs
Trauma resuscitation isn’t hard
• Airway control
• Breathing control
• Chest decompression
• Vascular access
• Resuscitation
• Diagnosis of injuries
• Access to a consultant
• Registrars can do all
of these things
The impact on training
• Like it or not, registrars need to be trained
– This requires exposure to the job
• The best exposure is one of graduated responsibility
– This includes leading the trauma team
• If the trauma calls are always led by a consultant, registrars will never have the opportunity to learn how to do it
• 24/7 consultant led trauma calls would have a negative impact on training
The practicality
• Surgical, anesthesia and intensive care consultants are largely out of the equation
• That leaves emergency medicine consultants
– It just isn’t practical to staff all of our hospital EDs, 24/7 with emergency medicine consultants
• The cost of doing so would be prohibitive
Summary
• There is no good evidence supporting consultant led trauma teams
• What evidence we have supports other factors being more important in determining outcomes than the presence of consultants
• Most trauma interventions can be performed by registrars
– Trauma calls are an important part of training
• It isn’t practical or economical to have 24/7 consultant led trauma teams
• Conclusion – 24/7 consultant led trauma teams do not produce better outcomes
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Ministry of Health
