-----Original Message-----
From: Rowley Cottingham [mailto:[log in to unmask]]
Sent: Friday, January 12, 2001 8:51 PM
To: [log in to unmask]
Subject: Re: Do UK paramedics get enough trauma experience ?


>To an extent we
>need to look at two issues; unit exposure and personal exposure. An 8
Consultant A&E is
>inevitably going to dilute individual
>experience quite considerably, while a small unit with active Consultant
staff who attend trauma >calls in person is likely to have a much
>greater individual experience

I agree- on this issue, I feel patients would be best served by units with 2
to 4 consultants living close to the unit and coming in for every major
trauma or critically ill patient to combine maximum 24/7 consultant
availablity with maximum exposure for each consultant (and if this creates
too much total workload, cut down minor injury/ minor medical problem
workload to the minimum to maintain competence- probably about 5 cases a
week). My feeling is that non resident consultants have as good results in
trauma as resident.


A bit more controversial, but do you have any evidence that individual case
load affects outcome? I know I argued that it did, and I believe that it
does, but I can't find the evidence to back myself up. Can anybody help me
on this one?


References:
Demarest et al: In-House Versus On- Call Attending Trauma Surgeons at
Comparable Level 1 Trauma Centres: A Prospective Study, J Trauma 1999 46
(4): 535- 9.

Luchette et al: Impact of the In- House Trauma Surgeon on Initial Patient
Care, Outcome and Cost. J Trama 42 (3): 490- 5 purports to show benefit on
mortality from in- house surgeons in the abstract, but in the body of the
paper it does not (interestingly, they did show an improvement to times to
certain interventions, but only during daylight hours).

Rogers FB; Simons R; Hoyt DB; Shackford SR; Holbrook T; Fortlage D: In-house
board-certified surgeons improve outcome for severely injured patients: a
comparison of two university center, J Trauma 1993 Jun;34(6):871-5 really
compared attendings with residents.

(Other papers mainly look at Trauma surgeons from the pure operating
viewpoint. I accept my search strategy may be at fault and would welcome
other comments.)

Podnos YD; Wilson SE; Williams RA: Effect of surgical panel composition on
patient outcome at a level I trauma center, Arch Surg 1998
Aug;133(8):847-54. 12 general surgeons had as good outcomes as 4 trauma
surgeons (each seeing more cases)

Schiowitz MF: Patient throughput and mortality rate in a trauma service.  Br
J Surg 1990 May;77(5):497-8. Basically a case report of a low volume surgeon
with good results

Cooper A; Hannan EL; Bessey PQ; Farrell LS; Cayten CG; Mottley L: An
examination of the volume-mortality relationship for New York State trauma
centers.  J Trauma 2000 Jan;48(1):16-23. In New York State, the hospitals
with the smallest case load had the best results (not statistically
significant)

The whole question of volume/ outcome relationship is one we (and
politicians) probably accept without questioning it enough. For some
conditions (e.g. breast cancer), it probably holds true (although often at a
fairly volume- for most conditions 20 or fewer cases seems to be optimal for
surgeons); for others (e.g. AAA), the evidence is far from conclusive, with
poor quality  and contradictory studies; for others (e.g. colonic cancer), a
lot of the evidence points towards better outcomes in smaller units.

Rather than compare major trauma to Whipple's or switch operations, which
are highly technical operations needing 'good hands' (and this could explain
the difference in results- only technically good surgeons do a lot of them.
Compare it to the - possibly apocryphal - figure that orthopaedic surgeons
who do the most han surgery get the best results from hip surgery); it might
be fairer to compare it to oncology where small units with a close knit team
(i.e. oncology units) provide better care than larger teams (i.e. general
physicians). This could explain why smaller units have better outcomes.

Matt Dunn
Warwick