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Volume 1 Issue 3 May 1996 Contents:
INTRODUCTION: Welcome to the third edition of Trauma Grapevine. We all hope that this issues will reach its target- all hospitals in South Western Sydney and others interested in Trauma within Australia. To facilitate its distribution Michelle McClymont will coordinate regional distribution. Liverpool Hospital as the Area Trauma Hospital for South Western Sydney accepts that it has a responsibility to hospitals receiving trauma within the region. We offer a hotline for inter-hospital trauma transfers and are aware of some of the dimculties involved. These difficulties were recently highlighted by a very welcome presentation at a recent Trauma Audit meeting from a Medical Offhcer (MO) at a nearby hospital. His tale is told below, but hrstly Dr Martin Jones from Nowra shares with us his recent Sunday afternoon on duty. "My Sunday Afternoon - The Frustrations of a Country Surgeon" My hospital is staffed by Visiting Medical Officers and 2 - 3 Casualty Medical Offhcers, restricted to Casualty Duties. It services a non-holiday population of 70,000 people. (NB No on-site U/S or CT Services). As the Duty Surgeon I was called to Casualty to attend to 3 victims from an MVA. All three people were wearing seat belts and two (the driver and front seat passenger) were wearing stiff neck collars on arrival to Emergency. The Driver sustained a fractured sternum, three fractured ribs and minor lacerations . She was treated by narcotic infusion, on a cardiac monitor in ICU with chest physiotherapy as adjunct therapy. The FrontSeatPassenger, had a stable C2 fracturel fractured clavicle, fractured left sided ribs and a left pneumothorax. The Back SeatPassenger, had a stable C2 fracture, right sided rib fractures and distended tender abdomen (NB non-English speaking). After transfer of first patient to ICU, I made three telephone calls to convince ambulance control that we needed a second Jordan frame. A diagnostic peritoneal lavage was performed on the second passenger which revealed frank blood. Then an intercostal catheter was positioned in the first passenger. I rang the pathology technician and convinced him to provide appropriate blood for transfusion. With resuscitation in progress it was obvious that the first passenger was stable, the second needed a laparotomy and both needed a place in a Hospital with Spinal injuries capabilities. Two Teaching Hospitals were rung and a total of 9 different registrars were spoken with, and of course the 1-800 retrieval number was rung (adding more and more time on the telephone).Each different registrar was told of my qualifications and the capabilities of the hospital. Some laughed, some hung up and I was called an idiot for working without a registrar, neurosurgeons and orthopaedic surgeons. After 43 telephone calls and abuse from obviously city-orientated registrars the helicopter arrived and transported the first patient, enabling me to take the second patient to theatre. A large tear in the liver, colon and mesocolon were treated and controlled. (I was able to discuss this witha specialist at one of the hospitals - very helpful). The patient was maintained on a Ventilator unffl I called the helicopter back to retrieve this woman. As I was finishing this case, another crash victim was arriving by ambulance in Casualty with a fractured neck: There were two children with acute appendicitis and other miscellaneous surgical problems. MARTIN G. JONES MB.BS.FRACS Standish Medical Centre 33 Berry Street NOWRA NSW P.O.Box 988, Nowra NSW 2541 Telephone (044) 23 2299 Saturday Night Fever - The story of a recent Interhospital Transfer.
On the 21/3/1996 a 55 year old male was brought into an urban hospital, in our region, unconscious, thought to be intoxicated. There was not a clear history of a fall but he was found at the bottom of a stairs. CDA Times 22:53 Booked 22:56 Out 23:02 Location 23:28 Destination En route to hospital a small amount of blood was noted from his nose and mouth. 23.35 Hospital Triage (There had been no notification of impending arrival to the emergency department) Primary Survey A Unconscious, GCS 7, C-Collar in place B RR 16/m 98% sats C P 64/m BP 140/90 D Responding to painful stimuli, Pupils 5mm R= L Smelt of alcohol and was bleeding from nose and mouth. He vomited twice and was suctioned. Radiology (23.45) C spine - Subluxation of C3-4? CXR - Clear SXR - Fronto-occipital # Cannulated and bloods taken Call 1 MO rang the Liverpool Trauma Hotline 00.30 requesting transfer. The MO was asked to intubate the patient by the ICU registrar. As there were no beds at Liverpool Hospital the MO was informed that he would be rung back with a bed location. Call 2 The MO rang Liverpool Emergency as no reply had been received in 20 minutes as the Liverpool ICU registrar was now busy in operating theatre. The Medical Officer at the urban hospital was unhappy to intubate. Call 3 ICU registrar rang MO informing him that he had located a bed at RPA. His instructions were for the Urban Hospital to arrange Careflight and intubate the patient Call 4 MO contacted Anaesthetic VMO who agreed to come an intubate patient Call 5 Careflight contacted- "busy on a job"- contact Lifeguard Call 6 Lifeguard contacted 01.30. Expected arrival 1 hour. 3 attempts at intubation by VMO Anaesthetist failed. 03.15 Careflight arrives Intubation was extremely difficult due to a previous tracheostomy 04.35 Patient departed Urban Hospital for RPA and had an extradural haematoma drained after CT scanning . He is recovering well. Comment. This case highlights me difficulties involved in offering telephone advice. The MO at me urban hospital did not have me skills to intubate me pah'ent and quite rightly did not affempt to do so. As it happened there was great difficuffy with intubation. The case identifies the importance of the best use of resources and the difficulty in obtaining a clear history in an unconscious patient. It would have been ideal if pre-hospital triage had directed this man to Liverpool in the first place. There must be greater empathy from major trauma services when dealing with urban and rural hospitals who may not only see major trauma infrequently but do not have the resources or manpower that Area Trauma Hospitals can provide. SWAN IV The full program and registration forms are available. Please register early as the registration is limited. TRAUMA FELLOW Dr Janjua and family will be arriving in early May as your new Trauma Fellow. We look forward to his contribution. TRAUMA TIPS - POINTS TO REMEMBER Early Response for MajorTrauma Notification of arrival of hypotensive (BP~9OmmHg) patient involved in serious trauma needs the following done before the paffent arrives; Group O blood in resus room Level one primed Radiographer ready with CXR plate on bed Pelvic Xray under table If GCS less than 10 alert CT Alert Surgical VMO To be optimally cost conscious, accurate and updated pre-hospital information is vital. THE LATEST IN TRAUMA .O'Malley and colleagues from New Jersey report on the Pulmonary Embolism afier Pelvic fractures. In a 2 year period (1988-90) when DVT prophylaxis was not mandatory 6% (18/301) developed a PE. In the ensuing 2 years DVT prophylaxis was compulsory and the rate fell to 0.7%. (3/386). Vena Caval filters were used in patients undergoing acetabular fracture repair with some success. They concluded that rigorous DVT prophylaxis provides adequate protection against clinically evident PE.Trauma 1996 Jarl p 182 CASE OF THE MONTH A 49 yo female was pinned in her car following a head on collision with a lorry. At scene: A OK, B RR 32/m laboured, C BP 80/- P120, D Responding to painful stimuli Rx: Oxygen 35%,C Collar, IV fluids (1.5 Haemaccel) Morphine 1 Omg IV Legs were trapped under the dash board. Extricated after 25 minutes. Bleeding from left leg with penetrating injury to popliteal fossa - Tourniquet applied to left thigh. Resus Room 55 minutes after accident On Arrival: A OK, B 28/m Equal Air Entry, C BP 90/50 ,P124/m, External bleeding from left leg now controlled. No other obvious source of blood loss. Abdomen soft and no obvious signs. D Responding to verbal commands, GCS 13. Rx: IV converted to rapid infusion set with O -ve blood administered. Tourniquet re-applied . No active bleeding. Patient dropped GCS to 11. CT rung for CT head prior to exploration of left leg but CT tube had just blown. WHAT WOULD YOU DO NOW? ~Should the patient be transferred to another hospital with a functioning Head CT before or after the popliteal fossa is explored ~Does the patient need intubation? ~Should the patient have an angiogram prior to surgery? These questions and the patients outcome will be discussed next month South Westem Sydney Regional Trauma Registry. Erica Williams, Data Manager for South Western Sydney Regional Trauma Registry recently took time out from generating the 18 month registry report to present a paper at the Auckland General Hospital in New Zealand. This paper highlighted the need for quality maintenance in the Registries. In the next 2 weeks a review of Trauma demographics and treatment in South Western Sydney will be published.For information on the registry Phone 98283929. ORGANISING TRAUMA RETRIEVALS CALL THE MEDICAL RETRIEVAL COORDINATION CENTRE (MRCC) 1-800-650 004 # Request to speak to a retrieval doctor about a potential retrieval. # The MRCC will normally expect you to have organised a bed at a receiving hospital. THIS CAN DONE BY RINGING THE ICU REGISTRAR ON THE LIVERPOOL HOSPITAL TRAUMA HOTLINE NUMBER 02 98283666 If this is an urgent transfer and you do not have time to do it yourself, tell the MRCC this - they and the retrieval doctor(s) will be able to help with this, freeing you to continue to manage the patient. Where appropriate a retrieval team wi!l be dispatched to you immediately, even before a bed is found. The retrieval doctor will be able to advise you on interim management- if necessaly while enroute to your hospital, and will decide whether a retrieval team or an alternative is appropriate, and what is the appropriate mode of transport. Retrieval doctors are consultants or senior registrars in critical care
specialties (anaesthesia, emergency medicine or intensive care) who work
for either NSW Medical Retrieval Service (the medical division of CareFlight)
or the St George Hospital Aeromedical Retrieval Service. Both services provide
retrievals by road, helicopter or fixed wing. They are based in West and
East Sydney respectively. This guide to retreival has kindly been produced by CareFlight by Dr Blair Munford and Bernie Hanrahan with minor modifications. POINTS FROM THIS MONTHS TRAUMA AUDIT The recent high rate of splenorrhaphies was noted and emphasis was placed on the importance of splenic salvage Diaphragmatic injury may benefit by early intubation and positive pressure ventilation to help reduce traumatic hernial contents Multiple trauma patients requiring surgery may require multiple operating teams working simultaneously Limb fractures can be fixed under regional anaesthesia. There is often little benefit in deferring the reduction of #. Early involvement of Orthopaedic registrars is critical in provision of state of the art trauma services. The Trauma Department would like to acknowledge the support of Hoechst Marion Roussel in the publication of the Trauma Grapevine Photographic services to the Trauma Department has been provided for 3 years by Elite Heathcote Road 98212522 Copyright 1996 Trauma Department Liverpool Letters to Dr Michael Sugrue Trauma Department Liverpool Hospital Elizabeth
Street 2170 or Fax 98285305
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