Training for trauma care

All of the components of these guidelines require skill on the part of the practitioners. Some of these are skills at all levels of the health system and by all levels of providers, such as the skills for initial evaluation and resuscitation. Some are only for hospital workers and some are highly specialized, such as those for operative management. In this manual, we have concentrated on skills for the main care providers, including doctors and nurses. However, it must be recognized that a variety of other professionals are involved in the care of the injured patient. Their skills and training must be considered, including laboratory technicians, X-ray technicians, operating theatre personnel and village health workers. Optimizing the trauma-related skills outlined in these guidelines is a major way in which the EsTC standards can be assured in a cost-effective manner.

Greater attention is needed worldwide to define and optimize the training of doctors and nurses in trauma care. This pertains to both trauma-related skills imparted in basic education and those acquired during postgraduate training, such as house-officer posts and specialist training for doctors. The tables in this manual outline the core set of trauma-related skills that are needed. It is hoped that by so doing this manual will provide guidance for curriculum development in schools of medicine and schools of nursing.

Higher-level skills for operative care require specific training. In rural, low-income environments, most notably in Africa, there is often a need for general practitioners to perform a variety of surgical procedures. In such environments, it would be useful to comprehensively address the appropriate elements of operative care that should be worked into basic medical school curriculum and house-officer training. This would assure that all graduates going to work in rural hospitals would have the skills needed to perform the procedures safely. In all environments worldwide, there is a need to consider the trauma-related skills that are imparted to surgeons in training during their residency. This applies to general surgeons, orthopaedic surgeons and others. Greater standardization of such curricula would assure increased availability of trauma-related services worldwide. In some environments, trauma services might be advanced by promoting an increased number of trauma fellowships after the completion of formal residency training. This would especially be the case for large urban trauma centres in middle-income countries.

In addition, continuing education for all practitioners involved must be promoted to prevent decay of cognitive knowledge and skills, especially among those who are not seeing large numbers of trauma patients. Such continuing education also provides updates to all practitioners, no matter what volume of trauma care they are handling. Finally, continuing education courses offer the opportunity to better define the core essential elements of trauma care for a given environment. By so doing, they can influence the trauma-related knowledge and skills imparted in undergraduate and postgraduate training. Continuing education courses have been documented to improve the process and outcome of trauma care. For example, Ali et al. (13, 14) evaluated the effect of regular provision of the two-day continuing education course, Advanced Trauma Life Support (see below for further details), at the largest hospital in Trinidad. Most of the doctors providing care for injured patients at that hospital had taken this course by the late 1980s. Compared to the period before such widespread trauma training, the authors noted an increase in appropriate use of several therapeutic modalities, including early (in the emergency department) endotracheal intubation of patients with severe injuries, early insertion of chest tubes in patients with severe chest injuries, and the use of urinary and nasogastric catheters. These improvements in the process of care were associated with a substantial decrease in the mortality rate of severely injured patients (injury severity score of 16 or higher) treated at that hospital. The mortality declined from 67% to 34% after most of the doctors had been ATLS-certified.

A variety of different courses have been utilized worldwide. We provide here brief descriptions of a selection of these. These guidelines do not formally endorse any one more than another. One or more may be optimal for a given environment.

• Advanced Trauma Life Support (ATLS): This is a proprietary course provided by the American College of Surgeons (31). It is the longest standing and most widely utilized continuing education course in trauma care world wide; since its inception in the late 1970s, over 350000 doctors have taken this course. The course lasts two to three days and covers the breadth of trauma care, oriented primarily towards the first hour of care in an emergency department. It includes didactic lectures and skill stations, where key technical skills can be demonstrated and practised using mannequins and anaesthetized animals. It is oriented towards the circumstances of developed countries. However, it has been found to be useful in some middle-income countries, as described above for Trinidad (13, 14). It has been formally established in 42 countries, including 23 high-income countries, 17 middle-income countries and 2 low-income countries. Formal promulgation to low-income countries has been hindered by start-up costs of around $80000 per country (50).

• National Trauma Management Course (NTMC): This course has been developed and implemented by IATSIC. It has been established principally in India, in partnership with the Academy of Traumatology (India). It has been running since 2000 and has trained over 1500 doctors in India. It is a two-day course oriented towards care of the severely injured during the initial emergency period. It is specifically oriented towards circumstances in India and other low-income countries. The curriculum contains lectures and teaching of life-saving skills on mannequins and animals. NTMC was introduced with faculty from IATSIC, but is now offered jointly with local instructors trained through an instructor programme, aimed at making it self-sustaining in the long term. There were no start-up costs involved, so the introductory expenses could be contained, and the course fees are subsidized to make it affordable in the local context.

• Definitive Surgical Trauma Course (DSTC): This is another course developed and promoted by IATSIC. It is oriented towards surgeons and is focused on operative management of some of the more difficult life-threatening injuries. The course emphasizes decision-making, using short lectures and discussion of case scenarios, and provides practical training in operative skills and strategies, such as thoracotomy incisions and access, laparotomy strategies, neck exploration strategies, management of solid and hollow visceral injuries, injuries to retroperitoneal structures, cardiac injuries and vascular injuries of the neck and chest. This two-day course includes lectures and surgery on cadavers and/or anaesthetized animals. It has been taken by over 500 surgeons, in 11 countries, since its inception in the early 1990s.

• Essential Surgical Skills (ESS): This course has been run by the Canadian Network for International Surgery (CNIS) in partnership with departments of surgery in several African countries, including Ethiopia, Malawi, Mozambique and Uganda. The curriculum content and implementation are managed by the Africa Canadian Committee for ESS, which includes representatives from each surgical department. It is designed to train primary care practitioners in the management of surgical problems commonly handled at rural hospitals. It includes two introductory lectures, 25 case studies and 40 technical procedures using mannequins and animal material. It lasts five days and covers the breadth of emergency surgery. Two of its five modules address trauma (e.g. anaesthesia & life support and orthopaedics & traumatology). It has been taken by over 3000 persons in the above countries since its inception in 1994 (for further information, see

• Primary Trauma Care (PTC): This course is administered by the PTC Foundation. It has been funded, in part, by the World Federation of Societies of Anaesthesiologists (WFSA). It is designed to train doctors, nurses and other health professionals in the early management of severe trauma at rural, GP-staffed hospitals. It lasts two days, with lectures, skill stations and moulage scenarios. It also covers disaster management and issues pertaining to the prevention of injury. It has been held in 23 countries in Africa, Asia and South America. In each country, local institutions adapt the template from the WFSA as needed to address the local environment. It has been running since 1996 and has trained several thousand practitioners. The manual has also been adapted for a WHO publication, Surgical care at the district hospital (26, 51).

• Kwame Nkrumah University of Science and Technology (KNUST) Trauma Course: This course was developed in response to the particular needs of rural hospitals in Ghana, which are almost exclusively staffed by general practitioners. It is oriented not only towards initial emergency care, but also towards definitive care appropriate to rural African hospitals. 150 doctors have undergone training on this week-long course since its inception in the mid-1990s. This is considerably less than the above-mentioned international courses, but nevertheless, this course demonstrates a model national trauma course developed to meet the specific needs of rural areas in a low-income country (/2). The course covers the breadth of trauma care, including knowledge and skills in:

— initial emergency management that should be applicable under any circumstances;

— definitive management which can reasonably be carried out in a rural African hospitals;

— diagnosis of more complicated injuries that would ordinarily be considered as warranting referral to a higher level facility; and

— reasonable management of such injuries when referral is delayed or impossible.

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