-----Original Message-----
From: Adrian Fogarty [mailto:[log in to unmask]]
Sent: Wednesday, January 17, 2001 9:44 PM
To: [log in to unmask]
Subject: Re: Do UK paramedics get enough trauma experience ?


>Also you've quoted papers
>about surgeons' performance, but they all examine "in-house" surgeons.

I agree that most did, but Demerast el al compared in house with on call
surgeons (admittedly in an area where on call surgeons had a response time
of 15 minutes- probably more practical here than in parts of London). Not
much evidence here, though.

>I disagree that one needs 5 cases per week of major trauma to maintain
competence.

Sorry, expressed myself badly here (on an issue in which we're probably very
much in agreement). I meant 5 cases of minor injuries or minor medical
problems was enough to maintain competence in these. My point (in the light
of recent controversy in EMJ about some A and E consultants wanting to pull
out of minor injuries) was that we have plenty of scope to cut the amount of
time we spend dealing with minor injuries without affecting our competence
with these cases, whereas we might benefit from seeing more critically ill
patients.
My own feeling is (as you say) that one case a week of major trauma is
enough. Of course, as stated, before, I have been unable to find any
evidence as to how many cases are optimal or even whether a volume/ outcome
relationship exists. I'd love to see some good evidence, though.

>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.

I was looking at the oncology side ( because this has been looked at a lot
elsewhere). Even in a smallish DGH without specialised oncologists, you
might have 10 consultant general physicians, a similar or higher number of
trainees and 70 or more nurses, along with various ancillary staff. There
are a lot of different people pulling in different directions, so although
it is a 'team' in the sense that it provides a service (oncology in this
case), it doesn't function as well as the much smaller pure oncology
services.
My point was that maybe the reason the specialised services achieve better
results is not that they have more experience, but that they function better
as a close knit 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.

Yes, I agree with you on this one. I don't think I used the term 'skill'.
Differences in outcomes from operations are determined to a large extent by
what the surgeon does during the operation. Outcome from trauma is probably
determined more by what's been done to your 'unit' in the years prior to the
trauma occuring. This is why I keep bringing up oncology rather than
surgery- I think the comparison is more relevant.
I do like to think, however, that the ability of the team leader has a
significant influence on patient outcome from trauma (otherwise, why get out
of bed for it?). If we put it all down to organisational and educational
achievements, we're making a case for single consultant departments with no
clinical input, and putting the money saved into surgeons.

Of course, we're both oversimplifying an A and E consultant's work here-
major trauma is a small part of our workload, and I think the influence of
consultants' skills on outcome will be found more in critically ill medical
patients and complicated 'minor' injuries. Direct clinical skills are more
important here.

Matt Dunn

Warwick