Dr Kevin Lai MBBS FACEM

It’s 4pm. Bat call comes in. Major Trauma. MVA, high speed roll over, deceased passenger, polytrauma, haemodynamically labile.

Trauma Team is assembled.

You are the Emergency Physician, team leading, organising your team and resources, overseeing the primary and secondary survey, supervising and performing resuscitation procedures, coordinating Trauma surgery, anaesthesiology, intensive care, orthopaedics, neurosurgery, as well as imaging, blood products…

The patient arrives, 30 yo male, HR 160, systolic BP 60, agitated, saturating 88% on oxygen. Large left side haemothorax with multiple fracture on CXR, positive eFAST for intra-peritoneal fluid, pH 6.98, lactate 8.6. You orchestrate the symphony of resuscitation: Primary and Secondary survey, IV and IO access, MTP, TxA, Calcium, ketamine, antibiotics, fluid warmer, left finger thoracostomy followed by chest drain, modified RSI. You do a recap, discuss with the surgeon and the anaesthesiologist. Patient is rushed to the operating theatre.

You sit back, debrief your team, and reflect on the success and challenges in the case. You wonder what is happening to this patient, what did they find in the laparotomy, will they need to do a thoracotomy, how may more blood products will the patient require, did some of your decision pay off, were they off the mark? But no, you are brought back by the next ECG shoved in front of your nose…

Now imagine the same scenario in another world,

You follow this patient into the operating theatre, whilst anaesthetic and surgical teams are setting up laparotomy, you interpret the TEG result, arrange further balanced product resuscitation, you keep an eye on timing, remind the theatre staff to keep the room and the patient warm.

Damage control surgery starts with a laparotomy, which finds a large left diaphragmatic tear, with a grade 5 lacerated spleen half sucked up into the left thorax, there is large gastric tear with plenty of enteric contamination. The spleen is pulled back into the abdomen and removed, the diaphragmatic tear repaired, the tear in the stomach is sutured, and the abdomen washed out with buckets of warm saline. Chest drain output is minimum. Patient stabilised after surgical control and 2 rounds of MTP. You take the patient to CT with the anaethesiologist.

CT finds minor cerebral contusions, multiple facial fractures, multiple left rib fractures with flail segments, bilateral pulmonary contusions, grad 3 left renal laceration with retroperitoneal haematoma but no active blush, left scapular fracture, and a comminuted left proximal humeral fracture.

You instruct your team to contact the relevant subspecialty and leave the patient in the care of ICU.

On the second morning, you lead the Trauma Round with your team of Trauma Fellow, Residents, Interns and a senior Trauma Nurse. You see all the new admissions overnight. You review this patient, as well as all the other 23 patients, typically male, but also increasingly frail crumbly elderly falls. You discharge a handful of patients, make decisions on next step actions based on recent progress and investigations of few other patients, get frustrated by a few geriatric patients who are waiting for their rehab or residential care placement as their acute trauma issues have resolved.

The issues you deal with include the more acute ones such as whether and when to start TPN on the new trauma patient, how often do you check Hb, what’s the patient’s ventilation status, what’s the patient’s fluid balance, when to start DVT prophylaxis as this patient has a high risk, as well as some of the less acute issues such as when do you start the patient on post splenectomy vaccine and antibiotic prophylaxis, what is timing for his facial injury surgery…

After 3 days, the above patient is extubated, but develops a fever, has large left pleural effusion, and a small to moderate pericardial effusion. After cardiothoracic consultation, decision is made for surgical drainage of the pleural effusion, but non operative watch for the pericardial effusion…

By 11am, the round is done. You have coffee with your team, go through all the patients, leave the Fellow to distribute the tasks to the juniors. You go to office, check on the images of the new patients, work on the next clinical audit, or a research project, until you are called upon by the next Major Trauma Call.

This is what I do for a whole week, as the Trauma consultant for a Level 1 Trauma Centre, in Sydney Australia. I am responsible for all the existing and new trauma admissions to the hospital. All the trauma admissions come under my name. I am onsite from 0730 to approximately 1600, but am on call in the evening. I don’t really get called into the hospital during afterhours, as the Fellows are senior, and are supported by the Trauma Surgeons if urgent surgical interventions are required. I handover to another Trauma consultant on Sunday, and start my next week as the Emergency Physician.

I am not a surgeon. 

This is the model of a Multidisciplinary Trauma Service that has sprung up in Australasia and in Canada in the past 2 decades. (1)

The background to the rise the Multidisciplinary involvement into Trauma is several fold: Trauma is increasing less of a surgical disease (but I am quick to stress that surgery is very much an integral part of trauma management); trauma surgery has lost some of its shine since the 1980s due to its afterhours nature, and relative less renumeration than other surgical specialties; other critical care specialties are more than capable of coordinating the multi-faceted acute Trauma care; the broad medical scope of Emergency Medicine provides an excellent base for looking after patients with a wide range of underlying medical issues, especially in the face of the so called “silver tsunami” – geriatric trauma; last but not least, the highly trained “non-technical skills” (communication, conflict resolution, resource management) that is integral in critical care makes these non-surgical clinicians highly suitable in team leading and coordinating multidisciplinary patient care.

Of course, the extension of our scope into in-hospital medicine, means we need to extend our knowledge in the next step management of trauma. This comes with active learning on the run, self-directing studying in courses and conferences, as well as in attending clinical audits and participate in research projects. But this is no different from furthering our knowledge into any subspecialties of Emergency Medicine, such as toxicology, retrieval medicine, ultrasound, geriatric and palliative care.

Currently two thirds of Major Trauma Centres (MTC’s) in Australia and one third of MTC’s in New Zealand has a multi-specialty medical specialist staffing models in their inpatient trauma services. The number and mix of specialties involved is varied, (general and orthopaedic surgeons, intensivists, anaesthesiologists), but the most common non-surgical specialist is the Emergency Physician.  Non-surgical specialists are often part of the leadership (director or co-director) in these trauma services, and majority of them are Emergency Physicians. (Private Communication)

The Australasian College for Emergency Medicine (ACEM) is actively building and expanding opportunities for its fellows (FACEM) and trainees to gain training and employment in Trauma Medicine. For some, like me, have been involved in the development and evolution of this growth in the past decade, and are seeing the advantage of having a balanced work load outside Emergency Medicine, networking with other subspecialty as an equal (rather than the “creator” of work asking a “specialist” to see your patients), and sharpening and widening our clinical acumens and knowledge base so that we can do better in our initial management of trauma cases in the ED. (2)

There has been debates on what title to adopt by the specialists in this new subspecialty. “Trauma Specialist” seems to be a better term than “Trauma Physician”, “Traumatologist”, “Trauma Consultant”.(3)

Going forward, perhaps more formalised post graduate training in Trauma, as a fellow, or a master’s degree will be required to enter the subspecialty.

But for now, it’s still a new subspecialty for Emergency Medicine, which presents exiting opportunities for us to step in and carve another career path for the ever dynamic, curious, and smart Emergency Physicians.

References:

1.        O Lavigueur, et al. “The Effect of a Multidisciplinary Trauma Team Leader Paradigm at a Tertiary Trauma Center: 10-Year Experience. Emergency Medicine International. 2020; doi: 10.1155/2020/8412179

2.        ACEM website: https://www.youred.org.au/read/trauma-medicine-skills-and-opportunities

3.        C Bowles. Is a trauma surgeon always a trauma specialist? Injury 54 (2023) 3-4; https://doi.org/10.1016/j.injury.2022.11.071