And one thing I've noticed in London particularly is that we virtually never see paeds trauma any more (which I'm not complaining about). They used to talk about a trauma peak in childhood but that's much more evident in the older age groups now. I suppose kids just don't "muck around" and play the way we used to: they don't walk to school on their own - they get "chauffeur driven" everywhere - and this is much more noticeable in the last 10 years.
Meanwhile there are more older people around who are gradually reverting to childhood levels of psychomotor skills, except they don't have parents shepherding them round, hence they get injured. We see a lot of "geriatric" trauma these days.
This is what is coming. It has
been trailed for a while, and (say it
ever so quietly) there is some sense in it. The honest (and rather
brutal) truth is that there just ain't enough major trauma out there to
justify lots of units able to handle it. It was Phil Belsham who first
pointed out to me the fact that by international standards we have
stunningly low levels of trauma in this country. Our traffic is so
congested and moves so slowly on the whole that significant RTCs are now
restricted to cars full of lads at 1am. Most modern cars are binary; you
either get out with relatively trivial injuries or are killed. I'm
painting a broad canvas, but think about it. We see lots of ISS of 9 and
less, and not a lot >35 until a bulge at 75. Logically, with hospital at
night and expensive trainees we are as a country not able to afford such
a luxury. I am not sure about the networks concept; you can bleed out
very swiftly from an abdominal stabbing, and it's
pointless going
somewhere where that can't be fixed.
I think that the number of units accepting major trauma will be cut
dramatically within 5 years. The corollary to that is that we are going
to have to think very hard about prehospital management as it may be
prolonged and we may need to look at the prehospital skillmix - work
currently ongoing with the HEMS and CCP projects.
What bothers me is that we are continuing to train large numbers of SpRs
in Emergency Medicine, and the logical conclusion of the above arguments
is that many of our trainees will be commanding minor injury units with
medical assessment units, not Trauma Units as in the traditional DGH
model. I'm not sure we or they have grasped this yet, and I see little
evidence of debate about this at CEM. Is this where we want to go? It's
all very well to have a new college and a new HQ, but we need to look at
what job we are doing and what job we want to
do.
> *From:* Andrew Webster <[log in to unmask]>
> *To:* [log in to unmask]
> *Date:* Thu, 23 Mar 2006 21:39:01 +0000
>
> More rationalisation of services threatened with PBR?
>
> Acute plans call for A&E split
> Emergency surgery and trauma services would not need to be provided
> on the
> same site as accident and emergency departments under controversial
> proposals submitted to the Department of Health.
>
> The National Leadership Network, which was asked by the government to
> draw
> up plans for the shape of acute hospitals under choice and payment by
> results, has specified what it sees as the 'core' services to be
> protected
> at all hospitals with A&E departments.
>
> The proposal to protect some services responds to concerns that the
> new
> market could lead to the closure of services which were
financially
> unviable
> but needed to support A&E.
>
> The document identifies the services – such as 24-hour access to acute
> medicine and diagnostic radiology – which the authors say should be
> protected.
>
> But they say some other services, such as emergency surgery, which are
> required by A&E teams need not be provided at the same hospital, but
> elsewhere locally.
>
> These services should be protected by the beefing-up of multi-hospital
> networks, perhaps through the establishment of joint ventures between
> trusts, the report says.
>
> Primary care trusts and practice-based commissioners will also be
> expected
> to ensure all patients have access to the necessary A&E services.
>
> Project director Martin Hensher said: 'Present multi-hospital
> networks are
> soft partnerships between trusts and in some places there are
reports
> of a
> bit of trouble where foundation trusts are part of networks.
>
> 'We have suggested ways of making networks more robust organisational
> structures, with firm contracts between trusts.'
>
> The document says A&E departments should be supported on site by
> 24-hour
> access to acute medicine, level-two critical care, a
> non-interventional
> coronary care unit, an essential services laboratory and diagnostic
> radiology.
>
> However, the following services need not be provided on site and
> should be
> supported by 24-hour local multi-hospital network access:
>
> emergency surgery; trauma and orthopaedics; paediatrics; obstetrics
> and
> gynaecology; mental health; specialised surgery and interventional
> radiology.
>
> Dr Dermot O'Riordan, chair of the Royal College of Surgeons
> reconfiguration
>
working party, said if there was not emergency surgery on site, an A&E
> department would not be able to admit someone with, for example,
> intestinal
> bleeding.
>
>
/Rowley./
