Trauma training in Australia and New Zealand: results of a survey of advanced surgical trainees.

BACKGROUND: The surgical management of trauma within Australia and New Zealand has recently been undergoing major organizational changes. The aim of the present paper was to evaluate the attitudes and experience of Australian and New Zealand advanced surgical trainees in this changing climate and to identify problems with trauma training. METHODS: A survey assessing important areas of trauma management and training was sent to all advanced surgical trainees of the Royal Australasian College of Surgeons. RESULTS: Two hundred and seventy-two of 587 trainees responded (46%). Overall 85% of trainees believed they would be involved in trauma management in the future. The majority of trainees reported low rates of involvement and consultant supervision in trauma resuscitations. Only 32% of general surgical trainees believed that their exposure to major trauma operations was very adequate despite an average of 12.3 trauma operations per year. Seventy per cent of general surgical trainees reported a very adequate level of consultant supervision at trauma operations. In contrast 86% of orthopaedic trainees reported a very adequate exposure to trauma operations with an average of 221 orthopaedic trauma operations per year. Only 46% of orthopaedic trainees reported a very adequate level of consultant supervision at trauma operations. CONCLUSIONS: Regional rotations may need to be developed to even out trainees' experience in trauma management. The low level of supervision in trauma resuscitations and orthopaedic surgical training requires attention. This survey warrants repeating in a prospective manner.

The major trauma management study: an analysis of the efficacy of current trauma care.

BACKGROUND: An audit of the management and outcome of major trauma patients was carried out to determine ways in which the system of care may be improved. METHODS: The Major Trauma Management Study (MTMS) collected data prospectively on all consecutively admitted major trauma patients at eight major hospitals during a 12-month period. Outcome was studied using trauma and injury severity score (TRISS) and a severity characterization of trauma (ASCOT) analyses, as well as a preventable outcome analysis, which looked at survivors with complications or with a Glasgow Coma Score < 15 on discharge from hospital, as well as studying deaths. RESULTS: The group of 859 patients was more severely injured than most described previously, with a mortality of 14.8% and a mean injury severity score of 19.8. Formal ASCOT analysis indicated 2.25% fewer survivors than would be predicted by Major Trauma Outcome Study norms. Extrapolating the TRISS and ASCOT process to include those patients with missing data, and then comparing groups of matched severity with the norms, gave no statistically different outcome in the MTMS group of patients. Preventable outcome analysis revealed rates of preventable and potentially preventable (P/PP) outcomes of 32% among deaths and 8% among survivors. The types of management deficiencies responsible for P/PP outcomes are identified. CONCLUSIONS: The points of deficiency in a system of care have been identified, and the development of an integrated trauma system in Victoria, based upon these facts, is recommended. Children, the elderly, patients with head injuries and patients being transferred between hospitals would benefit from improvements to the system of care. The calculation of efficacy rate (0.95 for the MTMS patients) is recommended to accurately assess the system of care. Preventable Outcome Analysis is more relevant to auditing a system of trauma care in detail, than is ASCOT or TRISS. The MTMS has refined and defined the process so that it is reproducible in further comparative studies.

Laparotomy for trauma in a regional centre: the effect of delay on outcome.

From 1983 to 1990, 110 patients with abdominal trauma required laparotomy in the Albury-Wodonga region. Splenic and liver injuries occurred in 50% of cases, and bowel trauma in 20%. The mortality rate was 8.2% (nine deaths) and major postoperative complications occurred in 18 patients (16%). Delay in therapeutic intervention of greater than 4 h from hospital admission led to a statistically significant increase in the complication rate (P < 0.01) despite a lower injury severity score in this group. Delayed repair of bowel injuries in particular led to an 80% major complication rate in survivors. A high index of clinical suspicion and the regular use of diagnostic peritoneal lavage is suggested to avoid such delays in diagnosis and subsequent surgery.

Intra-operative colonic lavage: safe single-stage, left colorectal resections.

Fifty consecutive left-sided colorectal cases are described in which intra-operative colonic lavage (IOCL) was used. Sixteen were acute or sub-acute cases, including five with total colonic obstruction. The anastomoses were usually hand-sutured and no colostomies were used: all procedures were single stage. Only one case was considered to have possibly had an anastomotic leak (2.0%) and the average hospital stay was 16 days. There were 3 wound infections (6%). Peri-operative mortality was 6% and no deaths occurred in the acute or sub-acute cases. The procedure allows safe one-stage operation in most acute left-sided colonic lesions and provides the most thorough colonic preparation for elective cases, thus obviating the need for colostomy in cases where the colon is found to be inadequately prepared, or in very low anastomoses. The technique described for IOCL is readily reproduced, attendant with negligible risk of complications and takes relatively little extra operating time. Defunctioning colostomy is unlikely to be necessary with this method, thereby saving patients considerable discomfort and nuisance, time in hospital and the potential morbidity of further operation. Specific recommendations for use of IOCL are: acute or sub-acute left colonic obstruction: stenosing or volvulus; massive colonic haemorrhage: for diagnostic and preparatory use; rectal and left colonic trauma; left colonic surgery where inadequate pre-operative bowel preparation has occurred; 'low' elective restorative rectal resection; and preparation for colonic replacement of oesophagus.

A perspective on the early management of abdominal trauma.

Blunt trauma in Australia is most commonly due to road accidents and is often multisystem in its effect on the body. Whereas some cases of intra-abdominal injury result in massive bleeding, and may be readily diagnosed clinically, many abdominal injuries are difficult to diagnose on initial clinical examination. Delays in treatment can result in otherwise avoidable morbidity and mortality, and the practice of diagnosis by repeated clinical examination over long periods of time is to be condemned in principle. All abdominal injuries can (and should) now be diagnosed and treatment commenced within 2-4 h of admission to hospital. Diagnostic peritoneal lavage (DPL) is the most sensitive indicator of intraperitoneal blood after trauma, and if employed early, and interpreted with a low threshold for positivity, early treatment of all intraperitoneal organ disruption can be undertaken. The best organ-imaging technique available for abdominal trauma is computerized tomography (CT) scan, but it is not as sensitive as DPL in the diagnosis of haemoperitoneum, and its accuracy in defining bowel injury is not proved. Several factors dictate the choice of DPL or CT scan in difficult trauma cases, and these include the stability of the patient, the availability of CT scan, the experience of the treating physician with either modality, the organs most at risk of injury in any case, and the decision to attempt conservative or operative management. In a small number of cases, doubt may still exist after CT and/or DPL, and an early laparotomy remains the 'gold standard' of diagnosis in such situations. In penetrating trauma, laparotomy is indicated if wound exploration shows penetration of the peritoneum.

Early management of abdominal trauma: the role of diagnostic peritoneal lavage.

This report reviews the contemporary value of diagnostic peritoneal lavage (DPL) in the assessment of abdominal trauma, and reports the methods and results of its application within one trauma centre (Washington Hospital Center). DPL was reserved for those patients where doubt existed as to the presence of intra-abdominal injury, and gave a very accurate assessment of intraperitoneal injury. The complication rate was 0.4% and the accuracy of DPL was 97.7%. Except for laparotomy, DPL is the most sensitive indicator of haemoperitoneum available. It was first introduced with the aim of reducing the number of missed diagnoses of abdominal injury and it performs this task excellently when a low threshold for positivity is used. The open technique is safest and gives fewer false positive results, and the colorimetric method of analysis of lavage fluid is recommended, with strict adherence to advised criteria for negativity. A clinical algorithm is described, utilizing DPL, aimed at early diagnosis of all intra-abdominal injuries. This was extremely sensitive and failed in only one case in 384 (0.3%). The attendant, non-therapeutic laparotomy rate was 19%, and is regarded as acceptable within the aims of early diagnosis. In this series, there was no mortality or morbidity attached to the use of DPL or from non-therapeutic laparotomy, and there was only one delayed diagnosis in the entire series. No bowel, bladder, diaphragmatic, duodenal or pancreatic injuries were missed or diagnosed late.

Emergency thoracotomy.

Eighty-nine consecutive trauma patients, who were treated at one institution and received emergency thoracotomy, were studied. Although 76 (85%) of the patients had no vital signs at hospital arrival, 15 (17%) patients survived the emergency thoracotomy to progress to other hospital treatments. Ten patients were ultimately discharged, nine of whom have normal functions. Maintaining a broad set of indications for emergency thoracotomy may increase survival amongst trauma patients for whom the procedure is indicated.

A case of pancreatitis associated with gastrinoma.

A case is presented of a 56 year old man with a history of idiopathic pancreatitis and multiple admissions for Klebsiella sepsis from an intra-abdominal focus, who in February 1980, developed spontaneous jejunal perforations on two occasions due to multiple ulcers in the small intestine associated with multiple hepatic metastases from a gastrin-secreting islet-cell tumor (gastrinoma) of the pancreas. On searching the literature, no other record could be found of an association between pancreatitis and a gastrinoma, although in this patient the two disease processes appear to be inextricably related.

Emergency bay thoracotomy.

In recent years, there has been increased debate on the indications for and value of thoracotomies done in the Emergency Department for victims of trauma. The current literature, unfortunately, does not resolve many points of contention surrounding this procedure. Using strict terms to define Emergency Bay Thoracotomy (EBT), 89 consecutive patients seen over a 2-year period in a Trauma Unit were retrospectively reviewed and analyzed. Eighty-five per cent of the patients had no vital signs on arrival, yet the procedure proved to be valuable in sustaining life in 17% of patients, two thirds of whom were discharged, 90% with normal findings. A progressive increase in survival rate was observed with increased use of the procedure. A review of the prognostic factors found in this study and comparison with other published studies indicates that clear definition of the patient population and patient status is essential before aggregated data are used as a basis for therapeutic policies. Educational and research efforts must focus on determining which patients have zero prognosis after initiating resuscitation, rather than on denying care to any group, even when only a few will respond.

Haematemesis and melaena at St. Vincent's Hospital, Melbourne.

One hundred and fifty-three patients with haematemesis and melaena were studied retrospectively. The majority were managed in general medical units. Fifty-one per cent had a past history of peptic ulcer and/or bleeding, and only 9% had no identifiable predisposing factors. Endoscopy was the major diagnostic tool, with a diagnostic rate of 85%. Nineteen per cent of patients had no diagnostic investigations performed for varied reasons. The operative rate was 15% overall, with an operative mortality of 17%. The presence of other serious disease states concomitant with the haematemesis and melaena, and the presence of oesophageal varices as the aetiology, were both shown to be associated with statistically worse prognoses. Age of greater than 50 years and transfusion of four or more units of blood were also associated with a worse prognosis. Overall mortality was 14%, comparable to or less than that at several institutions, but more than double that of a Haematemesis and Melaena Unit in another Melbourne hospital [Br. Med. J. 1, 1238-40 (1979)] Patient population should be considered closely when comparing mortalities from different series. It is felt that results could be improved using a combined medical and surgical approach, and a set protocol of management, and that such changes should be monitored via a prospective study.