The recorded history of trauma resuscitation probably begins in 18th century London, where in 1774 a 3-year-old girl by the name of Catherine Sophie Greenhill was witnessed to have fallen from an upper storey window onto the cobbled streets below. A volunteer from the newly formed Humane Society arrived and applied an electrical current to her chest from a portable electrostatic generator, reviving the clinically dead child. Fast forward to the battlefields of France during the First World War and French physicians note that treatment administered within the first hour of injury resulted in improved mortality . The data would later inform R Adams Cowley’s Golden Hour concept. Dr Cannon observed during the same conflict evidence of poor outcomes in shock following intravenous fluid resuscitation in the absence of surgical haemorrhage control, however the benefits of permissive hypotension would be largely forgotten for the next three quarters of a century. The British (in their infinite British wisdom) started resuscitating with whole blood during World War 2, whilst their slightly slower American counterparts began by using plasma only, before noticing the inferior survival outcomes on the battlefields of North Africa and changing their protocols to include blood transfusion. Liberal approaches to blood transfusion in the civilian setting continued in the post-war years until the discovery of blood-borne viruses and the increased costs associated with screening prompted more conservative transfusion policies.
In modern day trauma resuscitation, major haemorrhage protocols are ubiquitous and we know that compliance improves outcomes. The debate in recent years has been more of a philosophical and tinkering nature. What constitutes a massive transfusion? Is it 4 units of blood and/or FFP within 2 hours? 10 units in 24 hours? Does it really matter? Should we be giving extra cryoprecipitate earlier on? Should it be guided by viscoelastometry TEG or ROTEM depending on which side of the Atlantic you’re on) and should it be 1:1:1 or 1:1:2? We’ve also seen the inevitable encroachment of machine-learning algorithms and Bayesian prediction tools.
Leaving all that aside, for the busy ED nurse or physician in the organised chaos of the civilian or battlefield trauma bay, the only thing that really matters is effectively keeping track of what products went in to the patient and when. The trauma team is often compared to a Formula 1 pit stop team. Everyone playing their minor role and doing it well in order to contribute to the overall slickness of the operation. Inevitably in the heat of battle some elements get overlooked. In my experience this normally becomes apparent during the clean-up and documentation when the question of “how much blood did we give?” gets asked. The number of empty bags on the floor almost never corresponds with the amount that was prescribed.
What is needed is a stand-alone system which incorporates the speed and simplicity of pen and paper, that provides real-time relevant information to all relevant parties and that does not require any significant IT infrastructural overhaul or change to institutional clinical processes to implement. A simple scorekeeper that performs a simple task well and can seamlessly fit in to any major haemorrhage scenario be it in the trauma bay, on the labour ward or even in the elective operating theatre. As we continue to develop ever more intelligent and complex approaches to trauma resuscitation the logistics of implementing effective strategies remains a challenge. We leave room for mistakes to happen and mistakes in medicine cost lives and money. Perhaps it’s time to apply a simple solution.
Obi Nnajiuba is a British surgical resident and current PhD student with a specialist interest in trauma, acute care, prehospital care, triage, mass casualty events and trauma systems. His postgraduate qualifications include an MSc in Trauma Sciences and membership of the Royal College of Surgeons of England. He is also a registered Motorsport UK physician, providing trackside advanced trauma care to competitors at world famous motor-racing circuits such as Brands Hatch, Goodwood and Silverstone.
