Medic One Funded Projects
Shock Trauma, Baltimore
Dr Kristina Rebecca Cranfield
Between November 2012 and February 2013, I was honoured to be awarded the inaugural Robin Mitchell Medic One fellowship. With regionalisation of trauma care in Scotland becoming a distinct possibility in the future, there have been advocates both for and against this. With a background of surgical training and an interest in management of major trauma, I chose to use this opportunity to compare and contrast UK practice with an archetypal level 1 US trauma centre.
The R Adams Cowley Shock Trauma Centre, at the University of Maryland Medical Centre, is an 800-bed teaching hospital in Baltimore. It is a national and regional referral centre and receives the most multisystem and neurosurgical trauma in the world outside of a military setting. It is recognised as a worldwide leader in trauma care, with the first fully integrated trauma and critical care centre in the world. There are 140 inpatient beds dedicated to resuscitation, surgery and critical care of trauma patients, with a third of these being critical care beds. It was named after a surgeon in the US army who was posted in France during WWII. He coined the phrase that we know so well in Emergency Medicine, that of the 'golden hour'. He advocated that all major trauma patients should be transported immediately to a place of definitive care rather than 'nearest hospital first'.
I spent half my fellowship in the Trauma Resuscitation Unit (TRU), and the rest with Trauma Radiology, looking at the role of ultrasound and CT. The TRU is entirely separate from the Emergency Department, and only accepts trauma patients brought in by ambulance or helicopter. It has 12 cubicles, each of which may hold up to 2 ventilated patients. Adjacent to the TRU, there are 2 CT scanners with 24 hour consultant radiologist presence, an MRI and angiography suite, and 6 dedicated operating suites which may run simultaneously. The helipad is located on the roof of Shock Trauma and can accommodate 3 helicopters at any time. In 2012, 8500 patients were treated at Shock Trauma. 26% had ISS>15, and 13% ISS >25, with an overall 97% survival rate. The day starts early at 5am, with a ward round of all patients admitted on the previous 'take'. The next 24 hours from 8am is spent seeing patients who arrive at the TRU with injuries from motorvehicle accidents, gunshots, stabbings, falls from height, and other serious mechanisms of injury. It is not uncommon for there to be 3 or more departmental thoracotomies per week.
There are multiple differences between UK and US practice but the most striking is speed and efficiency of patient care, well described by Dr Scalea, the physician-in-chief of Shock Trauma, as 'a ballet of organised chaos'. In less than 15 minutes of arrival, a haemodynamically unstable patient who has been shot in the abdomen, is already in theatre, having been simultaneously intubated, FAST scanned and rapidly transfused with blood products, by a team of up to 20 surgical, anaesthetic and nursing staff from the TRU and theatres. Some of the many other differences include choice of anaesthetic drug for RSI, transfusion of blood products based on mechanism, clinical findings and haemodynamics rather than Haemoglobin level, cervical spine immobilisation in all patients until cleared by MRI or clinically when GCS 15, rather than reliance on a negative CT scan, use of pan-CT in most patients (including some with lower mechanisms of injury), escalation to critical care of most patients irrespective of pre-morbid level of function, and opiate-based discharge analgesics as standard. With regards to education and training, there was heavy involvement of medical students in every resus, and a gruelling rota for trainees and fellows involving a 24 hour shift on the shopfloor every 3 days.
The fellowship provided an unrivalled experience to compare and contrast trauma care in the US and UK, and was an excellent educational and learning opportunity. So, was this fellowship beneficial to my training? Absolutely. Can we learn from the US and improve our processes of trauma care and outcomes? Definitely. Would I recommend this fellowship to other trainees? Without question.
For further information on the Robin Mitchell Medic One travel fellowship or my experience in the US, please email beckscranfield@googlemail.com.
For an inside look at the 'ballet of organised chaos' that is a normal shift at Shock Trauma, please click this link.
