Manual of Definitive Surgical Trauma Care, Fifth Edition

Kenneth David Boffard, Kenneth David Boffard

• Éditeur: CRC Press
• Année: 2019
• ISBN:
  9781351012850
• Édition: 5
• Sujet: Medicine
• Sous-sujet: Medical Theory, Practice & Reference

Developed for the International Association for Trauma Surgery and Intensive Care (IATSIC), the Manual of Definitive Surgical Trauma Care 5e is ideal for training all surgeons who encounter major surgical trauma on an infrequent basis.
This new edition includes both an e-version, and also a microSD card containing over 20 operative videos. The increasing role of non-operative management (NOM) has been recognised, and the Military Module is substantially updated to reflect recent conflict experience. An expanded section highlights trauma management under austere conditions.Written by faculty who teach the DSTC Course, this definitive and well established book focuses on life-saving surgical techniques to use in challenging and unfamiliar incidents of trauma.

Part 1

Trauma system and communication principles

1

Safe and Sustainable Trauma Care

1.1 Introduction

In terms of hazard, the injured patient faces ‘double jeopardy’: the risks to their health owing to the traumatic insult to tissue and physiology; and the risk posed by the therapy required to restore health. Minimizing the potential for iatrogenic harm through the provision of safe care is especially challenging in trauma owing to the complexity and urgency of major trauma as a disease. Factors such as injury severity, acute physiological derangement, temporal urgency limiting diagnosis, or physiological stabilization, a multitude of definitive treatment options and interdisciplinary specialist interactions, can combine to compound the risk of something going wrong.

Despite this, safer and better trauma care is certainly achievable by focusing on reducing the risk of harm to an already injured patient from both the injury and the treatment. Reducing the risk that the original injury poses to the patient involves both technical and systematic elements. The technical aspects include pre-hospital and emergency care, imaging, surgery, interventional radiology, and post-operative critical care, and are considered in detail elsewhere in this manual.

Treatment of major trauma is a multifaceted endeavour, set within a complicated system that comprises an almost infinite range of interconnecting ‘moving parts’. The difficult question of how to improve safety in trauma care may be simplified by taking a hierarchical approach, focusing initially on the individuals and teams that provide trauma care, and then adopting a more strategic perspective concerning hospital institutions, regional and national trauma networks and governance, and finally a consideration of trauma care on an international level.

The question of safe trauma care also requires an examination of the sustainability of trauma care within the workforce and training, and the role of innovative simulation models, research and innovation, translation from military experience as means to ensure that healthcare professionals working with trauma patients can continue to offer the very best care available, and the use of reliable existing data. The aim of this chapter is to iterate the minimal essential components of individual, hospital, and system practice in order to deliver safe care.

1.2 Safe Trauma Care

1.2.1 Individual Factors

It is accepted that in order to practise safe surgery in the trauma setting, the trauma surgeon and trauma anaesthesiologist must have undergone a validated general training pathway culminating in exposure to a period of specific trauma training. Domain knowledge and technical skills represent the foundational aspects, but by themselves are insufficient. Professionalism is also characterized by rigorous adherence to personal safety (personal protection, sharps, needle-stick, vaccinations), consistent use of the World Health Organisation Safe Surgery Checklist (see Section 1.2.6), and compliance with continuing medical education imperatives. However, the reality is that a significant amount of trauma care in the world is delivered by individuals who may not have had the requisite training nor resources required.

Over the past decade, the importance of non-technical skills (see also Chapter 2) has become increasingly well recognized. The nomenclature for such skills differs from sector to sector (e.g. medicine = non-technical skills; aviation = crew resource management (CRM) skills; social science = interpersonal skills; psychology = emotional intelligence; US Army = soft skills), but the competencies are broadly the same: teamwork, communication, leadership, decision-making, conflict resolution, assertiveness, management of stress and fatigue, workload management, prioritization of tasks, and situational awareness.1 Consistent delivery of non-technical skills is very important in minimizing error, as very few preventable trauma deaths are attributable to purely technical mistakes.

1.2.1.1 Heuristics AND Cognitive Biases

Inherent bias in cognition affects perception; such biases are a universal feature of human decision-making and result from default to heuristics; numerous, unconscious mental shortcuts that allow the brain to arrive at quick, but approximate, conclusions with limited information. Such heuristics are advantageous (and thus highly conserved in evolutionary terms) when time or resource pressure demands a quick solution or judgment under conditions of uncertainty or limited knowledge in dynamic, complex or dangerous situations.2 These cognitive short-cuts can help us manage:

●Information overload – quickly filter and skim data for importance.

●Lack of meaning – fill in the gaps if data is lacking and map it to existing mental model.

●The need for swift action – survival and success can depend on decisions without time for deep analysis.

●The need to remember – helps decide what new information to remember and what can be forgotten...