Military trauma care meets standards

Recent recommendations were made regarding trauma care in the UK by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD).

British military physicians at the UK military field hospital, Camp Bastion, Helmand Province, Afghanistan, evaluated their trauma cases against these standards. It is apparent that the trauma care provided to some people in Afghanistan outclasses that delivered within much of the UK.

Military medical teams

Background The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report on trauma management, published in 2007, defined standards for United Kingdom (UK) hospitals dealing with trauma. This study compared the NCEPOD standards with the performance of a UK military field hospital in Afghanistan. Setting UK military field hospital, Camp Bastion, Helmand Province, Afghanistan.
Materials and methods Data were collected prospectively for all patients fulfilling the trauma team activation criteria during the 3 months of Operation Herrick IXa (from mid October 2008 to mid January 2009) and combined with a retrospective review of prehospital documentation, trauma resuscitation notes, operations notes and transfer notes for these patients.
Results During the study period, there were 226 trauma team activations. Of those patients brought to the medical facility at Camp Bastion by UK assets, 93.7% were accompanied by a doctor with advanced airway skills, although only 6.2% of the patients required such an intervention. Consultants in emergency medicine and anaesthesia were present in 100% of cases and were directly involved (in either leading the team or performing airway management) in 63.5% and 77.6% of cases respectively. Of those patients requiring operative intervention, 98.1% had this performed by a consultant surgeon. Of those patients requiring CT, 93.6% of cases had this performed within 1 h of arrival.
Conclusions Trauma patients presenting to the medical facility at Camp Bastion during Operation Herrick IXa, irrespective of their nationality or background, received a high standard of medical care when compared with the NCEPOD standards

National Confidential Enquiry into Patient Outcome and Death recommendations
Pre-hospital care
All agencies involved in trauma management, including emergency medical services, should be integrated into the clinical governance programmes of a regional trauma service. Airway management in trauma patients is often challenging, and the pre-hospital response for these patients should include someone with the skill to secure the airway, (including the use of rapid sequence intubation), and maintain adequate ventilation.

Hospital reception
A trauma team should be available 24 h a day, 7 days a week. This is an essential part of an organised trauma response system. A consultant must be the team leader for the management of the severely injured patient.

Airway and breathing
The current structure of prehospital management is insufficient. There is a high incidence of failed intubation and a high incidence of patients arriving at hospital with a partially or completely obstructed airway. Change is urgently required to provide a system that reliably provides a clear airway with good oxygenation and control of ventilation. This may be through the provision of personnel with the ability to provide anaesthesia and intubation in the prehospital phase or through the use of alternative airway devices.

Circulation
Trauma laparotomy is extremely challenging and requires consultant presence within the operating theatre. If CT is to be performed, all necessary images should be obtained at the same time, and routine use of head-to-toe scanning is recommended in the adult trauma patient if no indication for immediate intervention exists.

Head injuries
Patients with severe head injury should have a CT of the head performed as soon as possible after admission and within 1 hour of arrival at the hospital. All patients with severe head injury should be transferred to a neurosurgical critical care centre irrespective of the requirement for surgical intervention.

Transfers
There should be standardised transfer documentation of patient details, injuries, results of investigations and management, with records kept at the dispatching and receiving hospitals.

A comparison of civilian (National Confidential Enquiry into Patient Outcome and Death) trauma standards with current practice in a deployed field hospital in Afghanistan.
Emerg Med J 2011;28:310-312