|South Africa's war against trauma|
|Friday, 02 March 2012|
The aims of the visit were to find out what lessons could be learned for military surgery from civilian trauma management and to share military trauma experience with the medical community in Cape Town.
This visit was hosted by Professor Del Kahn and the Department of Surgery at the University of Cape Town. The department is co-located within the Groote Schuur Hospital, which is a regional trauma centre and famous for fostering Christiaan Barnard’s pioneering cardiac transplant surgery.
The Trauma Unit is led by Professor Andy Nicol. In this South African model, surgeons manage the critically injured holistically from initial reception, resuscitation and diagnostics, through their operative interventions to post-operative intensive care and ward-based rehabilitation.
Professor Nicol reported a downward trend in the prevalence of trauma, but this is relative when compared to UK civilian experience. The unit is a beating heart of complex surgical cases, predictably filling over the weekend and focused on generating the capacity during the week for its next influx. The epidemiology is also substantially different to UK civilian or combat trauma. While there is a preponderance of blunt head injuries amongst the most critical ventilated casualties, similar to UK civilian practice, there is an alarming number of stab injuries.
"I have been blown up by the IRA, shot at and had RPG’s, mortars, SCUDs and rockets fired at me. But none of these are quite as sobering as being eyeball-to-eyeball with an enemy"
Familiarity with dealing with thoracic stab wounds has allowed the evolution of a system to discharge patients with simple pneumothorax in 48 hours – after cardiac and oesophageal injury is excluded, patients are allocated an armchair rather than a bed, together with a personal exercise bike to encourage re-inflation.
Some novel blunt trauma injury patterns were well recognised locally. When faith in formal justice is limited, miscreants may receive a ‘community beating’ with a hippo-hide whip (sjambok): this has the same effect as tenderising a steak with resultant rhabdomyolysis and associated renal failure.
Blunt trauma and stab wounds are unusual in contemporary combat trauma, where 85% of injuries are from blast and gunshot wounds. Lessons from the additional frequent gunshot wounds in this South African civilian setting must also be interpreted with caution in the combat environment as handguns (low energy transfer wounds) predominate in the civilian criminal community whereas military weapons produce high energy transfer wounds with gross contamination.
The management of trauma in this setting is further complicated by an estimated HIV population prevalence of 40% and common substance misuse that may promote violence – ‘TIC’ is the local name for the widely available methamphetamine smoked in a glass bulb (commonly a stolen car headlight), which is known to cause paranoia and psychosis.
Academic activities during the visit included lectures, teaching, conferences and hospital visits. The Penman Memorial Lecture itself was an overview of the advances in the management of critical combat injury with the evidence underpinning improvements in outcomes.
There were two opportunities to teach small groups of students (local and international attached students) that were structured as case presentations. I attended repeat patient rounds in the Trauma Unit, the Surgical Intensive Care Unit, the combined surgical round, and the transplant round. I was particularly struck with the pioneering work of Dr Miller in conducting HIV-to-HIV transplantation. The unintended consequences were a substantial increase in procedures with the removal of a former exclusion criterion, which had attracted criticism from hospital management. However, it was recognised by the wider community for the worldleading innovation it truly represented.
There was also opportunity to see the synergy of a co-located private hospital, particularly in relation to the specialist transplant surgery, which facilitated consultants moving easily between their patients in the public and private sectors. This had advantages in time management and educational opportunities for the juniors.
The hepatobiliary meeting included an evidence-based debate regarding the optimal surgical management of hydatid liver disease, (i.e. open or laparoscopic) and I also attended the regional Surgical Mortality and Morbidity meeting. The Surgical M&M meeting was preceded by the Trauma Unit M&M that reviewed in detail those cases that would be highlighted at the regional meeting: here I could draw many comparisons with military trauma governance. Since 1997, UK military has developed a sophisticated trauma registry that scrutinises the patient journey from injury to rehabilitation (or death) and uses structured near-real time feedback to drive continuous capability development.
This is resource-intensive, requiring a network of trauma nurse co-ordinators, researchers and analysts to identify the clinical lessons, manage clinical performance and use injury data to develop personal and vehicle protective systems. In this busy academic trauma centre in Cape Town there are no dedicated resources for trauma audit. I believe the international influence of the work conducted in the Trauma Unit would be substantially extended through exploiting the trauma audit opportunities; furthermore, systematic feedback from monitoring key performance indicators of the ambulance service and referring hospitals would enhance the trauma system. The strength of the military system lies in looking at the patient episode as a whole, not just the tertiary hospital component.
Two meetings were undertaken with Professor Mall in the Surgical Research Laboratory. His team have developed a particular expertise in the role of mucins, with work well progressed to identify if and why mucins in saliva inhibit the HIV virus – the question this begs is how the knowledge can be translated into a therapeutic advantage?
Two other hospitals were visited – the Jooste Hospital and the Somerset Hospital. Jooste is located in the township area of Manenberg, with 190 beds to serve a population of 1.4 million. It operates at 102% occupancy. I immediately had empathy with this hospital – it has a ‘field hospital’ atmosphere. It is close knit, has a great team spirit, is isolated and must manage complex cases with limited resources. It has an outstanding outcome for survival from penetrating cardiac injury (stab) – no doubt related to rapid decision making and immediate surgery. Here I also happened upon a recently qualified British military doctor who had arranged a short sabbatical – I commend both his initiative and judgement, as this is exactly the environment that will prepare you to work in an operational setting.
At both Jooste and Somerset I joined the rounds in the Emergency Department. In each hospital, the cases were predominantly ‘medical’ (as reflects UK civilian practice), but this very useful teaching forum is not one that is yet widespread in UK hospitals – perhaps because the obsessive fixation on the four-hour target to move a patient out of the ED would demand rounds every two to three hours, which may be restrictive.
Translating military learning
Some lessons have already been touched upon; specifically the value of an integrated end-to-end governance system that captures post mortem data as well as clinical data and uses the knowledge to not only drive clinical capability development, but also to prevent or mitigate injury. The resources to do this may appear daunting, but when offset against the costs to society of death and disability (lost tax revenue and criminal injuries compensation, for example) a strong financial case can be made. Direct observation identified some ‘quick wins’ to enhance capability based on military experience:
• The use of intra-osseous transfusion for adults as well as children. Delay in pre-hospital transfer and inadequate fluid resuscitation through repeatedly failed peripheral cannulation was witnessed. Intra-osseous systems are simple and rapid to use and robust for the prehospital setting – UK military use the EZ-IO (limbs) and the FAST-1 (sternum).
• PRBC and FFP are transfused in a 1:1 ratio for the critically hypovolaemic and this reduces mortality. When universal donor product is issued from the blood bank it is transported in an insulated box with an electronic timer that will sound at 10 minutes. This reminds the demander to return the product within 15 minutes of issue if it is not required, so it can be recycled.
• Thromboelastography. This has been used very successfully in the field hospital to help tailor the transfusion requirements of each patient according to their clotting profile – these requirements may be PRBC, FFP, cryoprecipitate, platelets, tranexamic acid, and rFVIIa.
• Integration of emergency physicians in trauma resuscitation. The South African model is successful in how surgeons have adopted a holistic management of the trauma patient. Emergency Medicine is a new specialty in South Africa and how it integrates in this model is evolving. UK military experience identifies how the emergency physician can add value through their training to work across boundaries (trauma, medical, toxicological, environmental, psychological) where there is commonly morbidity in more than one domain.
• Seniority saves lives. The military trauma team is consultant-based 24 hours-a-day and this contrasts sharply with UK civilian experience. At Groote Schuur there is recognition that trauma consultants are not resident out of hours and are on call from home – there is a desire to change this mentality, although with the small number of available trauma surgeons (each working two weekends per month) this is unsustainable.
Trauma heuristics: Professor Nicol had recently completed research identifying the high specificity of a straight left heart border on CXR and a ‘J’ wave on the ECG to diagnose haemopericardium (even in the absence of ultrasound evidence). Simple, pragmatic rules such as these are empowering in the field setting when diagnostic capabilities are often limited.
Accepting expectant patients: The volume of trauma is such that extended resources cannot be justified for patients whose injuries are judged irrecoverable. Patients with devastating head injuries who remain GCS 4T off sedation after 24 hours are deemed expectant and active treatment is withdrawn. This has been published as a joint approach between trauma surgeons, neurosurgeons and medical ethicists. It has clear resonance with the ethical challenges in a field hospital and provides a sound precedent on which to guide similar difficult decisions in the operational setting.
LODOX Scanner: A full body topogram is an early investigation in the Trauma Unit’s resuscitation bay. This is useful to identify long bone/pelvic injuries, the location of bullets, and the presence of pneumothoraces, all of which help to guide early intervention decisions. For the current military campaign, direct digital radiography and FAST scanning are used as bedside diagnostic imaging, with 2 x 64 slice dedicated trauma CT scanners available 24/7 with reporting from an on-site consultant radiologist. For future campaigns, LODOX may represent a lower cost alternative should a compromise be necessary in what can be deployed in support of the field hospital.
The complete experience
A highlight for me was a personal tour of the Transplant Museum at Groote Schuur Hospital, detailing the life of Christiaan Barnard and the conditions that led to him being able to perform the first successful human heart transplant in 1967.
An unexpected experience, but which nevertheless placed the visit in context, was to be mugged in broad daylight at knifepoint close to my hotel, by a desperate man high on TIC. The options were to kill, be killed, or reach a compromise. I was deliberately carrying little money and no credit card. I reached a compromise and walked away. He ran in the opposite direction with the equivalent of £5.
In my 28-year military career I have been blown up by the IRA, shot at and had RPG’s, mortars, SCUDs and rockets fired at me. But none of these are quite as sobering as being eyeball-to-eyeball with an enemy. As a close friend has subsequently said, any outcome where you walk away from a knife confrontation is a good outcome.
I am confident that the visit as Penman Professor has provided an opportunity to share military experiences from contemporary operations and that these will be reflected on by the hospital’s staff who can exploit the benefits within the context of their own infrastructure and organisation. This is, however, only symptomatic treatment for the high prevalence of trauma in South Africa. At the heart lies the continuing encouragement of societal and cultural solutions towards violence – there will be no Christiaan Barnard to transplant this heart, but it will represent no less an important transformative change.
Advancing medial practice in South Africa
The Frank Penman Memorial Foundation is a charitable institution established to advance medical knowledge and practice within the Republic of South Africa. This has been achieved through an annual Visiting Professorship to the University of Cape Town.
History demonstrates that military medicine advances in war and these advances benefit society in peace. The contemporary conflicts in Iraq and Afghanistan uphold this precept. Military trauma registries undeniably confirm the growing cohort of ‘unexpected survivors’ of critical trauma and have allowed detailed analysis of the underpinning reasons. The military imperative and political aversion to combat casualties has driven successive step and incremental change in the organisation, training, equipment and practice guidelines for the UK Defence Medical Services.
This has produced a profound strategic drift in the quality of trauma care, with the deployed British field hospital providing the exemplar to the National Health Service. This difference is publically recognised in reports of the House of Commons Defence Select Committee (2008), the Healthcare Commission (2009) and the National Audit Office (2010), who share the recommendation that military advances in trauma care need to be translated to the civilian community.
Colonel TJ Hodgetts CBE OStJ
Penman Professor of Surgery 2011, Honorary Professor of Emergency Medicine, University of Birmingham and Emeritus Defence Professor, College of Emergency Medicine