Trauma management

War is the only proper school for a surgeon. (Hippocrates, c. 460–370 BC)

Conflict has always been synonymous with disease and injury. As technology progressed and spears and swords were replaced by guns and bombs, the pattern of injury changed and the numbers of casualties increased. Throughout history, war has forced innovation in trauma management, and our recent conflicts in Iraq and Afghanistan have been no different. Many of the advances during this time were not new ideas but were evolved and improved to provide better point of care management and a more coordinated approach to casualty management throughout the evacuation chain. An example of this is the use of the tourniquet: in 2002, the traditional tourniquet was reinvented to enable one-handed self-application, allowing soldiers to treat their own upper limb extravasation1; in addition to this, there was a shift in the training paradigm to prioritise control of major haemorrhage in the Battlefield Advanced Trauma Life Support (BATLS) protocol,3 ensuring that all personnel involved in casualty management were checking and looking for the application of tourniquets; this has been further developed in 2018 when the ‘Catastrophic Haemorrhage, Airway, Breathing, Circulation’ algorithm was published in the civilian guide to the management of major incidents and mass casualty protocol when dealing with blast injuries.4 This single intervention, its development, application and coordinated use have been shown to reduce deaths significantly due to peripheral-extremity haemorrhage and, if applied prior to the onset of shock, has been shown to increase survival from 10% to 90%.5

In 2015, a 10 year review of casualties conducted by the US Military (2001–2011) found that 90.9% of deaths were due to haemorrhage,5 with 63.7% of lethal haemorrhage being due to a truncal site of extravasation.6 This highlighted a need for innovation in managing these casualties more effectively and finding a way of providing haemostasis in an austere environment, where a limited operating capacity might delay laparotomy or thoracotomy for aortic cross clamping and proximal control of bleeding. First described on the battlefield in 1954, resuscitative endovascular balloon occlusion of the aorta provides a rapid, effective solution to exsanguinating haemorrhage from pelvic and non-compressible torso haemorrhage.7 This technique of gaining proximal control of truncal haemorrhage has been demonstrated to be a viable alternative to resuscitative thoracotomy8 and can be used as a temporary anatomical and physiological stabilising tool in a deployed environment, when access to theatre and other resuscitative products may be limited. The use of this technique is gaining some interest in a prehospital and combat setting, as a bridging method of haemorrhage control. Due to this, in 2019, the American colleges published a comprehensive set of guidelines for its use within civilian trauma systems, based on a literature review with representation from the US Military.9

Innovation in trauma management, whether military or civilian, is continually developing: many advances made prior to 2009 have had a positive impact through their incorporation into civilian medical practice over the last decade (Table 1).

In addition to evolving the way trauma is managed, the military has invested in finding ways to prevent or minimise traumatic injury. An example of this is the development of personal body armour. From analysis of the data coming out of the recent conflicts in the Middle East, it was identified that the critical structures that need to be protected were the heart, great vessels, liver and spleen.10 In addition, further anthropometric studies were done to assess coverage of the protective plates used. These established that the use of surface landmarks was a more accurate measurement for body armour plate sizing than stature.11 The UK Home Office Body Armour Standard Guidelines, published in 2017, reflects this research in the recommendations for the minimum protective qualities of individual body armour used by police in the UK.12 With the number of incidents in which police firearms were discharged in England and Wales rising, from 4 reported in 2011 to 13 incidents in 2019,13 it is thought that this innovation in personal protective body armour will save lives, within both the military and civilian services.

Systems

The management of trauma and of major medical incidents is commonplace within the military; they are concepts that are regularly trained for through table top exercises, trauma courses and Hospital Exercise (HOSPEX) moulage training. While the BATLS course and the Military Operational Surgical Training course provide individuals with skills training to manage trauma, the table top and HOSPEXs enable healthcare providers to work as a team to triage, manage and evacuate trauma casualties. In addition, they must think about the larger operational picture with regard to resource and capacity management and how these factors will affect the capability of a treatment facility.

These concepts were trialled and tested during conflicts in Afghanistan and Iraq and saw the evolution of a consultant-led evacuation team to speed things up and to enable senior clinical decision making that would influence immediate treatment as well as evacuation planning.3 This resulted in better use of assets and a sustained capability to manage a large number of trauma casualties. These concepts have been adapted and transferred to the National Health Service through the development of major trauma centres (MTCs), the use of Major Incident Medical Management and Support course and the development of guidelines in 2018 for major incidents and mass casualty events. All of these tools help to save lives by streamlining resource and personnel management and by standardising our approach to trauma care.

Before 2012, the emergency care system in England had been based on geography: from point of injury to the nearest accident and emergency department regardless of that treatment facility’s resuscitation or surgical capability. The National Confidential Enquiry into Perioperative Deaths 2007 report suggested that almost 60% of major trauma patients received a substandard level of care, with avoidable deaths.14 This report led to a recommendation from the National Audit Office to reassess and reorganise the system for trauma management in England.15 Following this recommendation, a major trauma network was developed based on models used in other countries, such as the USA,16 17 which showed improved trauma care when care for a region is provided by a network of hospitals with MTCs at the hub.18 This concept was finally realised in England in 2012 with the reorganisation of our trauma system and the development of 27 designated MTCs. The Defence Medical Services (DMS) support these MTCs and, where possible, post military personnel to these locations to ensure maintenance of skills and continuity of military training and to enable transfer of knowledge: from lessons learnt during conflict to the civilian management of trauma. A still developing part of England’s trauma system is the forward placement of consultants on prehospital platforms. This alteration in the trauma pathway was shown, during conflicts in Afghanistan and Iraq, to increase survival and, when compared with the paramedic-led platform used by the US Airforce, was shown to have a lower mortality rate.19 Although not commonplace, a consultant-led service was adopted by the London Air Ambulance in 2017 and may have a place in other regions that have a high incidence of trauma with Injury Severity Scores of >20.3

In addition to innovation in prehospital care and MTC management of patients, the DMS have been able to use their wealth of experience in definitive surgery and rehabilitation for blast, blunt and penetrating trauma: in 2011, the National Institute of Health Research Centre for Surgical Reconstruction and Microbiology opened at the Queen Elizabeth Hospital in Birmingham. This brought together both civilian and military trauma surgeons and scientists to continue innovation in the care of trauma patients and used battlefield experience to benefit NHS patients at an early stage of injury. This was reflected in 2017, when the Manchester Arena bombings took place. The military aid to civil authorities (MACA) enabled the DMS to share their knowledge and experience with their NHS colleagues, influencing patient care and having a positive impact on patient outcomes. In addition to clinical advice, the DMS was also able to offer forensic pathology support, which enabled swift understanding of the major incident’s forensic picture and promoted a multidisciplinary approach to forensic autopsy that improved accuracy and specificity of forensic recovery. The paper by Bowley et al 20 that reviewed this collaboration concluded that the use of MACA to incorporate lessons learnt from a military perspective was invaluable and should become a standard operating procedure for such events in future. In addition, it was felt that applying this system to support the NHS made a positive contribution to the morale of NHS workers and had a positive impact on extending resilience of the workforce and their ability to adjust psychologically to the magnitude of such events.

Disease outbreak

Individuals

Serving in the UK military as a medical professional offers a unique opportunity to develop leadership and team working skills in addition to medical training. It is the experience gained and developed from exercises and deployments outside of an NHS setting that enables military personnel to offer an alternative perspective when returning to their NHS job roles. Positive contributions to these roles can be seen in a number of categories: leadership and management on the ward or within a specialty effective prioritisation of tasks, keeping calm to enable effective decision making in times of stress and clinical experience from situations not easily replicated within an NHS setting. These attributes have been recognised on numerous occasions by NHS trusts and have been more recently verbalised by the Chief Executive of Blackpool Teaching Hospitals NHS Foundation Trust who said ‘We recognise and value the skills and experience leavers and serving reservists bring to the workplace’.31

Future challenges

It is challenging to develop and maintain skills while not engaged in a deployed kinetic operational setting, as the patterns of injury seen are difficult to replicate on any kind of scale within the UK. Another complex challenge is in maintaining and learning the appropriate skills for deployed surgical care; small deployment teams mean that a broad range of trauma skills are required by relatively few individuals, which is difficult to obtain in an NHS training pathway directed towards subspecialty competencies. A recent paper by Breeze et al 32 explored these challenges and concluded that there were three main factors in mitigating against loss of skills and in provision of appropriate training: military-tailored fellowships, to provide opportunities to develop the extended competencies required in training, regular training courses to revise and review these competencies, and restriction of military consultants to work only at level 1/MTCs.