----- Original Message -----
From: Dunn Matthew
> 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.
Your idea may work in a rural environment, but "dashing" to work for
critical cases doesn't work very well in London. The surgeons can get away
with it but the A&E staff would miss the boat. Also you've quoted papers
about surgeons' performance, but they all examine "in-house" surgeons.
I disagree that one needs 5 cases per week of major trauma to maintain
competence; I would be seriously concerned about your ability to translate
from short term to long term memory if you did! One case per week of
anything is more than enough to maintain competence and many people,
especially surgeons, maintain specialist skills on much less than that.
> 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.
Don't confuse size of unit with centralisation. Many tertiary services run
with a small team, but the team subspecialise and see considerable workload.
I don't understand what you mean by equating general physicians with a large
team.
At the end of the day, I don't believe one needs a very high degree of
"skill" to run a trauma call well. Trauma outcome, I believe, depends
greatly on many other specialists, services and infrastructure, and to judge
a trauma service by the competence of the A&E consultant hugely
oversimplifies the management of this condition.
Adrian Fogarty
A&E Consultant
Royal Free Hospital
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