COVID-19 has us all between Scylla and Charybdis

In lieu of an efficacious vaccine against SARS-CoV-2, governments and individual households find themselves caught between the Scylla and Charybdis of COVID-related deaths and financial oblivion.   The pressures of mouths to feed, bills to pay and public services to run makes the global lockdown ever more difficult to sustain with each passing week.

The hunt for a treatment is in full flow. Early interest in hydroxychloroquine has been calmed by studies suggesting no consistent benefit in humans and the potential for cardiovascular side effects. Other options such as the antiretroviral combination drug Kaletra also showed no benefit beyond treatment with standard care, and tampering with the immune response via IL-6 modulation could be counterproductive.  Remdesivir, a broad-spectrum antiviral previously used against Ebola has recently received Emergency Use Authorization from the FDA following promising early trial results. However, while providing some mortality reduction, it is hardly the reassuring panacea that the public is searching for. World leaders have pledged billions in the search for a vaccine, which if it ever does come  is likely to be over a year away. Add to that the time is would take to manufacture and distribute the vaccine to 6 billion individuals worldwide.

Although the current (at the time of writing) US COVID-19 death toll sits at over 80,000 thus exceeding the 61,000 people killed by influenza in the 2017-18 season, it seems that we are increasingly willing to accept a certain level of risk if it means easing the lockdown restrictions. As the rate of transmission plateaus and falls in many parts of the world, rigorous testing, tracking and contract tracing may allow for less draconian social distancing measures. Apple and Google have recently partnered up on COVID-tracking technology by adding new features to their mobile operating systems making it possible for certain approved apps to use Bluetooth to track physical proximity between phones. If someone later receives a positive COVID-19 diagnosis, they can report it through the app, and any users who have been in recent contact will receive a notification. Unsurprisingly, China has been at the forefront of implementing tracking and surveillance technology with scant regard for individual liberties. We have yet to see how much personal liberty individuals are willing to sacrifice in places such as the US, in exchange for certain health benefits.

No government wants a second wave of COVID-19, not least because a glance back to the 1918 Spanish Flu shows how the second wave was far deadlier than the first. Couple that with the emerging evidence that the current coronavirus is mutating into a more contagious  strain and it’s easy to plot a theoretical positive correlation between the level of “return to normal” and mortality. And while there may be a theoretical linear correlation between increasing illness and mortality, it is clear that as the R0 increases, we rapidly move into an exponential increase in mortality, rapidly overwhelming our acute care facilities, and potentially requiring huge steps backwards to re-contain the spread.

The members of society with the most pressing need to return to work i.e. the low-paid, will most likely be those most at risk of contracting COVID and having a poorer outcome. These are members of ethnic minority groups with underlying health conditions such as diabetes, hypertension and cardiovascular disease and who may  often work in customer-facing roles in public services and/or live in overcrowded public housing blocks with reduced access to quality healthcare or insufficient insurance coverage.

Some countries such as Sweden and Belarus didn’t embrace the lockdown consensus, instead, either through intention (or in the latter case perhaps ignorance) pursuing a policy of developing herd immunity. Time will tell which was the wiser strategy. For the rest of the world  businesses and schools are starting to be allowed to re-open in a phased manner, often with regional variations based on the number of infections and deaths around different parts of a given country. The compulsory wearing of face masks has become a feature of the easing of lockdown restrictions in many places.

But what will the new normal look like? There will most likely be significant unemployment and the possible decimation of entire industries such as in aviation and tourism. But those lucky enough to return to work can expect to find smaller  reorganised workspaces with staggered shift patterns and break times, fewer communal spaces and a greater embrace of remote working and video conferencing. The group Chief Executive of Barclays recently hinted that big offices may be a thing of the past. While the lay public may think that the healthcare industry is immune to these trends, it appears to not be the case. On the contrary, due to the restrictions on elective procedures, and a likely exhaustion of public funding, many forward-thinking healthcare systems have started to make mandatory salary decreases of 15-30% for healthcare providers.

For the most part our health systems are starting to see some light at the end of the tunnel. The arrival of new patients is slowing, and many underutilised makeshift field hospitals are being mothballed. We may just be coming to the end of the first quarter in this heated viral play-off. We still need to ensure we have enough in the tank to see out the rest of the game and the challenges that it will bring. The one thing that seems to be certain is that we’ve only just begun to appreciate the effects of this illness on the economy, society and healthcare itself.

Obi Nnajiuba is a British surgical resident 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. 

@drnnajiuba

A simple AI solution at a time of international crisis

We stand in the midst of a global health emergency which threatens the very way we live our lives. At this time of unprecedented strain on health resources the concept of prehospital triage has never seemed more pertinent. Nearly half of the world’s population is effectively living under a form of regional or national ‘lockdown’ during which time they will be need to manage their physical and mental wellbeing, as well as being aware of the right time to seek medical attention.

 Luckily for us we’ve spent the past decade creating technologies that allow us to run our lives from our couch. From online banking to same-day shopping and food delivery, the prospect of a few weeks behind closed doors needn’t be as daunting or disruptive as it may have been in the not too distant past. After all, most people in their 30s can still just about remember a world before we had fast, reliable broadband in our homes.

 At a time when emergency lines will be jammed and EMS providers operating at full capacity it’s crucial that the public have a simple, accessible and robust solution to turn to. The newly launched Corona Screener is a self-explanatory decision tool website and app that takes users through a series of screening questions and guides them towards the most sensible course of action, be that calling 911 or simply following self-isolating procedures. Instructions to self-isolate can be followed up with enrolment into the Quarantine Companion program. This AI-driven text service proactively engages with the patient and advises at to when further treatment escalation may be necessary. It also provides regionally-customised tips for ensuring health during isolation and logistical strategies for maintaining life as close to normal as possible.

Mental health is widely expected to take a hit during this crisis, especially for the elderly, lonely or vulnerable barricaded inside their homes for weeks or even months on end. Knowing where to order groceries or your favourite take-out and being guided towards helpful and accessible psychological support services can give someone the light they need to make it to the end of the long COVID-19 tunnel.

 The trauma doesn’t stop completely during the COVID-19 pandemic. Despite a reported 50% reduction in trauma cases based on experience from Italy, the major cases still need ambulances to get them to hospital and dedicated teams to provide the best care possible. By keeping as many people as possible safely out of hospitals we can still provide the same high level of trauma care we expect from ourselves and our colleagues on any given day. Corona Screener will go some way to ensuring that our healthcare systems are not overwhelmed.  

Obi Nnajiuba is a British surgical resident 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.

@drnnajiuba 

Discovering the truth about life after discharge

As trauma and acute care surgeons we fix broken people with the aim of shipping them back out the hospital door as soon as possible. Pressures on hospital beds and the increase in the general pace of life mean that the good old days of spending 2 weeks being pampered in a hospital bed as you recuperate at a leisurely pace after a straightforward appendectomy or similar procedure are long gone. In an otherwise young and fit individual, as many of our patients are, and allowing for immediate post-op complications and difficult social circumstances, there is seldom a need to keep people in hospital beyond 48 hours. But how often do we stop to consider what life is like back in the real world as we send them off with instructions to complete a course of oral antibiotics, take simple analgesia and to pitch up in a follow-up clinic an arbitrary number of weeks down the line?

Well, in my case, never. Not until my wife’s appendix ruptured on my birthday. Following laparoscopic surgery, she was discharged the following day with antibiotics, analgesia and a follow-up appointment a few weeks down the line. For once I was seeing things from the other side. The dependence on analgesia once that local anaesthetic has worn off, the profound lack of energy, the weight loss and the frustration at the slow speed of recovery all became very clear to me. For a healthy, independent and successful professional (she’s a lawyer), the complete loss of control is somewhat disconcerting. It probably didn’t help being married to a surgeon who largely downplayed the seriousness of having a “straightforward procedure” to remove her appendix, or hearing me nonchalantly discussing how many I’d done on any given day, like it was nothing more than removing a sebaceous cyst under local anaesthetic.

In my own case I’ve just had an ACL reconstruction in one of my knees and was discharged the same day. Little did I appreciate that the uncomfortable paraesthesia involving  my entire leg caused by the pneumatic tourniquet would take 48 hours to wear off. I’m sure I’ve warned patients about it when consenting for similar procedures in the past, but having first-hand experience is an entirely different kettle of fish. Thankfully my skills and knowledge have allowed me to manage my post-op wound infections through self-prescribing of antibiotics and self-evacuation of pus (excruciatingly painful) saving myself a few needless trips back to the ED. In both our cases there has been the short-term knock-on effect on our careers and also re-jigging of childcare arrangements. It’s hard to jump into the car and pick up the kids from school went you can’t get out of bed or bend your knees.

My wife and I are still (thankfully) young, fit and anatomically whole. What about the polytrauma patient who lives alone and required an emergency above-knee amputation? Or the patient with the severe spinal cord injury? Rehabilitation service provision will undoubtedly depend on individual insurance cover. Even within nationalised health systems a ‘postcode lottery’ exists which some people will be able to overcome by paying for private rehab, whereas the majority won’t. There remains a need for greater integration of telemedicine and mobile services to help level the geographical barriers to receiving effective after-care. Whilst there are an abundance of good physical therapy app on the market, these are mostly directed at elective orthopaedic patients and fail to address the psychological and emotional needs of patients who sustain major trauma. Welcome innovations such as those developed by the AfterTrauma rehab team at the Royal London Hospital are filling a gaping hole in the market.

And what about the gang member at risk of recidivism once they’re fixed and put back out onto the streets (literally). Black males, alcoholics and those who sustain penetrating trauma have higher long-term mortality risks having survived their initial trauma admission. Inpatient programs which aim to catch young gang members in that “teachable moment” in the ED when their peers are often nowhere to be seen have been shown to have some limited effect. Ultimately a wider public health approach [HN4] to violence reduction is crucial.

Considering the realities of life for patients after discharge rarely occupies the collective conscience of acute trauma physicians. And not surprisingly so, after all there are teams of physios and occupational therapist roaming the hospitals under whose remit that falls. But it can be an enlightening and humbling experience to witness the realities first hand, an experience which can only improve us as doctors.

Obi Nnajiuba is a British surgical resident 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.

@drnnajiuba

The Financial Realities of Becoming a Trauma Surgeon

The ‘Jack of all trades’ nature of being a trauma surgeon requires clinicians to have a working knowledge across a broad range of subspecialties.  From orthopaedics and plastics, to neurosurgery and cardiothoracics, the general-surgeon-come-trauma-surgeon will often need to undertake additional fellowships and specialist courses to ensure they are adequately equipped to deal with the unique challenges that trauma patients pose. American trauma surgeons in many ways have it easy, with dedicated and defined residency programmes in high-volume urban areas that focus on trauma and surgical critical care. Elsewhere, in places such as the UK, surgical trainees mostly still have to carve out a bespoke career path for themselves and will often require a period of time abroad in high-volume trauma settings in order to fill in the gaps in their technical skills. All of this comes with a financial burden that many struggle to cope with.

A British surgical trainee having left medical school with tuition fee debts in excess of $65,000 can expect to  spend an average of $34,000  on courses, exams and conference attendance throughout the duration of their residency. Specialist trauma surgery courses offered by the Royal College of Surgeons include Definitive Surgical Trauma Skills ($1800) and the Pre-Hospital and Emergency Department Resuscitative Thoracotomy Course ($900).

US medical graduates with an average student debt of $180,000 will of course shed no tears for their less heavily-burdened counterparts overseas, however the issue of surgeons in financial difficulty both inside and outside of the USA is likely to be more prevalent than ever. A survey of over 100 surgical residents at the University of Wisconsin in 2015 reported 38% of respondents having more than $200,000 in educational debt, and 82% had a moderate or high risk debt-to-asset ratio.  A lack of financial literacy, the desire to play catch-up with their peers who qualified in other professions at earlier ages and salespeople trying to push any number of burdensome financial products on young residents are some of the key issues. A recent systematic review detailed the negative association between medical student debts and mental-wellbeing and academic outcomes. More worrying still is the ample evidence pointing to debt as a leading risk factor in suicide. 

There is an urgent need for more training in financial planning throughout medical school and residency. At Johns Hopkins University in Baltimore, Maryland, for example, the finance faculty created the Pillars of Wealth financial literacy initiative, aimed at teaching medical professionals to make better financial decisions. It is now offered to fellows, residents and staff physicians throughout the Johns Hopkins medical system.

Aside from greater personal financial education and responsibility, one would expect that state or government-led loan forgiveness schemes and greater regulation of the student loan industry may go some way towards easing the burden. Ironically, the fear of undergraduate and postgraduate debt burdens may push relatively higher numbers of medical students towards a surgical career path due to the higher earning potential compared to some other medical specialties. Although trauma surgery with its high emergency to elective work ratio and relatively low remunerations compared to other surgical subspecialties may not see the same staffing benefits. Ultimately, the long-term impact of student debt will have a negative impact on the overall numbers of people entering medical school, which will be to the detriment of society as a whole.

Obi Nnajiuba is a British surgical resident 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.

@drnnajiuba

Trauma Innovation: 2019 and beyond

Every passing year sees medical innovation and technology breaking new ground. From new drugs, devices and treatments to improvements in the day-to-day processes of care and new ways to secure and share patient data. This year has been no different. Here in no particular logical order are a handful of innovations in a variety of fields that have caught our eye:

Spinal trauma vaccine

A team from the University of Michigan have successfully used nanoparticles to reprogram innate immune cells, dampening the damaging immune response to spinal cord injury which further contributes to tissue degeneration. Furthermore, the site of spinal cord injury is infiltrated by pro-regenerative immune cell phenotypes and the expression of regeneration associated genes, which substantially improved functional recovery.

MTP Scorekeeper

With damage control resuscitation now standard practice, the simple practicality of keeping track of blood product ratios has been largely overlooked until now. This year saw the launch of the long-awaited MTP Scorekeeper. With its simple, intuitive and (crucially) portable design the trauma team can ensure the delivery of optimal transfusion ratios whilst limiting crystalloid use.

ShotSpotter

The scourge of gun violence continues to blight America. From a public health perspective, the Stop the Bleed campaign has been effective at spreading basic first aid knowledge to members of the public caught up in the aftermath of mass shooting events.  ShotSpotter is an acoustic gunshot detection system first developed in the 1990s which uses strategically placed sensors to detect gunshots and record contextual information such as location and type of firearm. The system can automatically dispatch law enforcement to suspected firearms incidents within seconds and is currently used by law enforcement in over 90 US cities and within the global private security industry. A study published this year analysed analysed over 600 shootings during a  9 year period in Camden, New Jersey both before and after the implementation of the ShotSpotter system. The study found that the system significantly decreased the response time of both police and EMS to the scene of a shooting and therefore allowed for more rapid contact with injured victims. Furthermore, the system’s use resulted in reduced transport time to hospital.

Drones

In March I wrote an article on this very blog page examining the use of drone technology in the treatment of the severely injured. Since then a comprehensive review looking into the utility of drones on the battlefield has been published highlighting the potential for greater integration into operations requiring crisis management, biochemical hazard detection and monitoring, casualty search and evacuation, blood product transport and telemedicine capabilities.  

Cerebrotech Visor

In December 2018 the UK’s National Institute for Health and Clinical Excellence (NICE) published a medtech briefing on the new Cerebrotech Visor. This device, resembling a VR headset is worn on the head of a patient and uses Volumetric Impedance Phase-shift Spectroscopy to detect asymmetry in bioimpedance measurements which may be an indication of stroke, bleeding and/or cerebral oedema. Although currently intended as a prehospital diagnostic tool for stroke patients, it’s not hard to see this technology being used to detect the presence and extent of intracranial haemorrhage following trauma.

Endo-SPONGE

Any surgeon that has ever done trauma or emergency general surgery has had to deal with an anastomotic breakdown at some point. As painful as these can be, both for the patient and the ego of the surgeon,  there's finally been a new approach after all these years. The Endo-SPONGE treats these leaks from a trans-luminal approach, with a 90.1% success rate. This is truly a breakthrough which proves how technology and innovation can solve a problem which has vexed surgeons for over 100 years.

The march toward artificial intelligence and beyond

The hot topic in all aspects of healthcare is artificial intelligence (AI) and how this will shape things in future. The use of artificial intelligence within the healthcare industry is expected to grow rapidly at an annual rate of 40% through 2021 – to $6.6 billion, from approximately $600 million in 2014. AI may be able to augment clinical judgement by way of early warnings about intraoperative events such as bleeding and flag action points such as hypothermia, aberrant anatomy, or instrument use that may be linked to the risk. In 2018 researchers from the University of Washington, Seattle developed an AI-based warning system called Prescience that predicts hypoxemia during surgical procedures up to 5 minutes before it occurs. This system monitors vital signs and provides the clinician with a risk score that updates in real time.

Augmented reality via hardware such as Google Glass has been around for a number of years and it’s use in helping run trauma resuscitations has been previously explored. No doubt there will be a continued interest in its use and other similar virtual reality endeavours such as holographic telepresence to truly bring the expertise required to the patient’s bedside regardless of the level of trauma center they find themselves in.

We live in exciting times for technological innovation and 2020 is expected to be no different. Trauma care stands to benefit hugely and that can only be good news for patients and surgeons alike.

Obi Nnajiuba is a British general surgical resident  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.

@drnnajiuba

Looking for my trauma mojo

Many of us will at some point opt or be forced by circumstance into taking some form of career break. Be it for research, parental leave, travelling, personal or family illness; the time off allows for a period of reflection and stock-taking that is seldom available to us when we’re on the relentless career hamster wheel. In many cases the hardest part is getting back on the grind having grown accustomed to the relative luxury of waking up AFTER sunrise, having time to go to the gym at a reasonable hour and seeing your kids during the week whilst they’re still awake.

 Re-discovering your mojo after a prolonged period away from work can be one of the toughest challenges physicians face, not least those involved in the unrelenting field of trauma care where the rewards of bringing someone back from the brink of death can easily be lost in a sea of violence, carnage and the haunting screams of bereaved families. But away from the emergency side of things we may find ourselves becoming disillusioned through lack of familiarity with changing work practices, a reduction in the perks and perceived prestige that once came with our jobs, changes in personnel and a general sense of having lost touch with the ‘wardcraft’ skills that enabled us to effortlessly command a team of juniors and multi-task to deliver effective care to our patients. Self-doubt and a low sense of personal accomplishment magnify the general sense of misery.

 Much of the difficulty is perhaps a realisation of the burnout we were experiencing before our time away from work. Over the past 20 years, physician burnout has become a well-studied field, with up to 50% of surgeons surveyed in the 2015 Medscape Physician Lifestyle Report describing symptoms of burnout, and trauma surgery in particular being highlighted in a separate study as a significant factor.

 Among many millennial surgeons such as myself there’s also this inescapable sense of the grass being greener elsewhere. We look to our high school friends and peers who went down different career paths and who make just as much or (more often than not) more money than us doing jobs that ostensibly involve less stress, less blood and faeces and more time with their families. I speak to my friends in finance about how they plan to spend their Christmas bonus, or my travel blogger buddy about their next exotic destination and as much as they respect and revere what I do on a day-to-day basis, I somehow doubt that any of them would swap their lives for mine. A new generation of wanderlusters fuelled on by endless images of ‘earth-porn’ on social media platforms or videos of luxury travel are pursuing  life goals and fulfilment away from traditional ‘respectable’ professions and prioritising their lives accordingly.

 As my attending points out, there is no shame is admitting that the career you once felt was your calling in life no longer seems as appealing as it once did. The long-term consequences of burnout in terms of patient safety, physician well-being and the smooth running of the trauma service overall are significant and potentially deadly. We owe it to our colleagues and the people we look after to bow out gracefully when the time is right. Stress management workshops and physician well-being programs to address the issues are all well and good, but at the heart of it we need to rediscover what it was that drew us to the profession in the first place. What was it that made me sit in the library at med school reading Top Knife into the early hours? What was it that made me volunteer my weekends away to help run student trauma conferences? What was it that drove me to look for trauma research opportunities and side projects as a medical student and newly qualified doctors?

 I believe that somewhere deep down in all of us that flame still burns but is at risk of being smothered by the stresses of academia, financial concerns, the demands of family and (in my case) a crushing sense of self-doubt. Somehow finding the right strategies to address or mitigate all of these is the only long-term route to survival.

Obi Nnajiuba is a British general surgical resident 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.

@drnnajiuba

Giving back to the community: Facilitating ethical research in the trauma setting

The Helsinki Declaration underpins the ethics of medical research. Yet the minds behind these noble and pivotal codes of conduct could surely have not envisaged the fast pace of cutting-edge emergency care delivered both inside and outside of hospitals in our modern healthcare systems. Furthermore, it fails to address the population-level community consent sometimes required to undertake health service research and evaluations. With community consent information about the study is provided to the local community of potential subject and it is explained that everyone in the community will be considered for participation unless they opt out.

Individualised informed consent which involves a detailed discussion of the risks and benefits of study participation allows for trust and confidence to be established between researchers and subjects and acts as the ultimate legal buffer should expected adverse events occur. But what about time-critical interventions in incapacitated patients? For a while it seemed that emergency care was forever condemned to be backed up by low-quality retrospective data. Ethics committees world-wide have begun to appreciate the need to expand the scope of emergency research to not only improve the quality of care emergency and trauma patients receive, but to also open up study settings that were previously inaccessible to clinical trials such as the pre-hospital environment.

The controversy surrounding community consent is perhaps somewhat overblown, given the history of futile interventions that trauma patients have been subjected to over the years both inside and outside of hospitals. Resuscitative thoracotomy following blunt trauma is still performed despite dismal outcomes overall. How about pneumatic anti-shock trousers, junctional tourniquets or other interventions with limited evidence bases beyond a handful of swine or canine models in controlled settings? Perhaps it’s not so much about the pitfalls of trying to establish a system of community consent, but more a question of why is this such a controversial issue given our history of subjecting incapacitated people to potentially dangerous interventions in their ‘best interests’? This despite there being no guarantee that our interventions aren’t causing more harm than good.

 A pragmatic approach is increasingly being taken to emergency and prehospital research. Much is covered by guidelines similar to the FDAs Exception From Informed Consent Requirements for Emergency Research (EFIC) which states qualifying conditions under which emergency research can take place, namely:

· The human subjects are in a life-threatening situation that necessitates urgent intervention.

· Available treatments are unproven or unsatisfactory.

· Collection of valid scientific evidence is necessary to determine the safety and effectiveness of the intervention.

· Obtaining informed consent is not feasible because the subjects are not able to give their informed consent as a result of their medical condition.

· The intervention must be administered before consent can be obtained from the subject’s legally authorized representative.

· There is no reasonable way to identify prospectively individuals likely to become eligible for participation.

· Participation in the research holds out the prospect of direct benefit to the subjects.

· The clinical investigation could not practicably be carried out without the waiver.

 The Centre for Trauma Sciences (C4TS) at London’s Queen Mary University is well versed in recruiting trauma patients into clinical trials directly from the resus bays of the Royal London Hospital, the busiest trauma centre in Europe. Whether it be observational coagulopathy studies, or a randomised control trial for REBOA consent is simply obtained from a senior member of the ED team who has no direct involvement in the trial and functions as professional legal representative. Written consent from the patient or next of kin is sought as soon after enrolment as appropriate. Most of the interventional studies tick all of the aforementioned EFIC boxes. Following enrolment of over 1800 patients to one particular study over a 10 year period at C4TS, only 5% of patients or relatives subsequently over-ruled the consent of the independent physician. Of course, the inability to reverse the original intervention and its effects potentially opens up the door to legal challenges from the study subject, irrespective of whether their next-of-kin consented on their behalf during their period of incapacitation.

 In the prehospital arena, studies such as the one looking at using whole blood on helicopters clear local ethics boards with similar ease owing to a culture of research and innovation which has been allowed to take root and flourish.  Another approach from the Royal London Hospital has been to display notices in the ED waiting room to inform patients that they may be enrolled into clinical studies and therefore consent is presumed unless patients specifically request opt-outs. Furthermore, trauma systems research into the development of refined triage tools may require cluster randomisation of entire communities and neighbourhoods. Presumed community consent is surely the only way to make all this feasible.

 From spring 2020 UK citizens will have to get used to a similar opt-out principle with regards to organ donation. It would therefore be unsurprising if presumed consent became the default position for a wider scope of emergency clinical trials in years to come.

Obi Nnajiuba is a British general surgical resident  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.

@drnnajiuba

If Congress won’t stop the shooter then teachers can Stop The Bleed

The arrival of the ‘back to school’ season focuses the mind on every parents’ worst nightmare. Since the watershed of the Columbine High School massacre 20 years ago an estimated 228,000 US school children have been exposed to gun violence during school hours. The issues of gun violence in America, and perhaps most sensitively the issue of school shootings remain a permanent fixture of political and social debate.

School are now being designed and built by the same firms that build jails. In addition to existing measures such as emergency drills, remote-controlled building lockdown systems, CCTV and security fencing;  school districts are also investing heavily in on-site armed ‘resource officers’ and mental health personnel. Many have advocated the extra step of arming teachers themselves and although this is already  legal in a number of states, the majority of teachers themselves are opposed to the idea. Just to play devil’s advocate for a moment, if the Geneva Convention allows for medics to use lethal force to defend themselves and their patients, is it too fanciful an idea to expect teachers to be morally bound to use lethal force to protect their children whilst in loco parentis? Just throwing that out there….

New schools such as Fruitport High, Mich. Are being built from the ground up with active shooter frustration in mind. Everything from curved corridors to limit lines of sight to ubiquitous ballistic-grade glass is being fully integrated into building design, fuelling a $2.7 billion school security industry. But should the worst happen and all the expensive security measures fail then the wounded and dying must rely on those in their immediate vicinity to deliver life-saving treatment before medical personnel are able to enter the ‘hot zone’. Teachers now routinely attend Stop The Bleed classes alongside the usual first aid training. In its first 5 years of implementation an estimated 125,000 US teachers received training in life-saving haemorrhage control. Tourniquets and haemostatic dressings are now as much a part of any classroom first aid kit as plasters and antiseptic cream. Some criticism has been levelled at the Department for Homeland Security for funding the program and also rolling it out among the pupils themselves, with accusations of treating the symptoms of gun violence rather than actually pushing for tighter gun controls and tackling the issue at source. One could also make the argument that these skills of emergency haemorrhage control are transferable and equally useful should the teacher or student witness a serious road traffic collision or other non-shooting related traumatic event in their community.

That may be more useful to the students and society than over-zealous active shooter drills that may indeed be causing more harm than good by forcing petrified kids to routinely contemplate their own violent death or filling their heads with far-fetched ‘tactics’ advising them to suppress a gunman by throwing school books or rocks at them.

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.

@drnnajiuba

Trauma Care 2050 Part II: New paradigms in surgery and ICU

Compared to trauma surgeons of today, the trauma surgeon of 2050 will probably know a great deal more about their patient and what’s going on inside them as they paint their torso with betadine. Injury mechanism and the specific location of bleeding vessels or damaged tissues may be more clearly defined, consigning the ‘exploratory’ element of the laparotomy to the history books. The risk of coagulopathy and multi-organ dysfunction will be known allowing for expedited or prolonged surgical procedures as deemed appropriate. The printing of organs known to be damaged beyond salvage may already be in progress in the lab adjacent the OR. The surgeon may have even been able to use augmented reality to rehearse their approach on that exact patient with their reconstructed images having been fed directly from scanner to surgical VR headset. Senior or specialist advice could be remotely sought from elsewhere with the images being securely transferred to an attending or consultant surgeon outside of trauma centre also utilising VR hardware.

Even today, after a decade of advances in damage-control resuscitation we’ve seen the implications of patients who previously would have died at the roadside surviving to get to the OR and succumbing to multi-organ failure on the ICU in the days that follow. By that same reasoning, further advances in prehospital and ED resuscitation may enable even more patients with significant injury burdens to find their way alive (just about) onto the operating table. This calls for advanced surgical techniques that avoid adding to the physiological stress of the initial injury. Nanotechnology will most likely play a significant role in achieving haemostasis. The use of nanobots as an imaging adjunct in locating bleeding cerebral aneurysms, delivering targeted thrombolysis in atherosclerotic disease and delivering targeted chemotherapy has garnered much interest in recent years. Even at the turn of the 21st century in-depth discussions were taking place about the potential for artificial mechanical platelets (clottocytes) inundated with haemostasis promoting proteins to control haemorrhage. Circulating ‘respirocytes’ may be able to maximise oxygen tissue delivery even in low-flow states. With regard to nerve injuries, advancements in technology have led to the development of devices on the nanoscale which allow manipulation of individual axons.

The greater use of nanotechnology to target hard-to-reach bleeding could facilitate a minimally invasive approach to trauma surgery. Furthermore, the knowledge that these nanobots could be left to quietly go about their business inside the patient could mean shorter times on the operating table, minimising the additional physiological insult of prolonged large-incision surgery. Patients could go to ICU with surgery ongoing inside them. The patient’s ICU journey could become more predictable and manageable with greater knowledge of the expected inflammation response owing to genomic analysis and artificial intelligence.

Patients will have greater control of their long-term rehabilitation with individually customised recovery plans and specialist support, building on existing services such as MyRecovery.AI and AfterTrauma. 

There is no doubt that the surgeon of the future will need to be ‘multilingual’ in a number of biomedical and allied disciplines, be it genetics, bioengineering, computing or data science. They will need to employ quick thinking and common sense to piece all the various bits of information together. Greater flexibility and multi-disciplinary collaboration throughout medical training will be crucial to this. Technology, however, can never replace the ‘human touch’, especially in a specialty where both patients and relatives will potentially be having the worst day of their entire lives. An in-depth technical and scientific must be coupled the timeless qualities of empathy and compassion.

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.

@drnnajiuba

Trauma Care 2050 Part I: From roadside to ED

Allow me to paint you a putative vision of trauma care in the year 2050 (assuming civilisation hasn’t been eradicated by climate change by then).

The predicted widespread use of driverless cars may  significantly reduce the trauma burden from road traffic incidents (see June’s article below).  But with the pressures of growing populations, stretched public services and rising social deprivation we can expect interpersonal violence to continue to provide a steady if not increasing flow of trauma cases.

 In the immediate aftermath of a violent or traumatic incident EMS dispatch is automatically triggered by distress signals from the victim’s smart watch-like device. This intelligent wearable tech will detect changes in stress hormones, nociception, significant force vectors and vital signs and relay these along with precise geographical data  to the EMS dispatch HQ.  Existing smart devices such as the Apple Watch Series 4 are already incorporating elements of this with their fall detection technology. First responders will receive all the relevant baseline vital signs and medical history such as anticoagulation status and allergies whilst en-route. Corroborating information garnered from bystander 911 calls will also add to the picture. Upon arrival at the patient’s side the EMS teams will already have an in-depth knowledge of patient physiology, injury pattern and mechanism, thus facilitating rapid triage to an appropriate level of trauma centre.

 Point-of-care genomic testing could feed into predictive models of coagulopathy, transfusion requirement  and subsequent multi-organ dysfunction, further informing the triage decision. Professor Tim Billiar’s group from Pittsburgh are one of several groups looking into the multitude of inflammatory mediators  and their underlying gene expressions that predispose different patients to develop multi-organ dysfunction following trauma. Real-time and predicted physiological data could be fed back to the receiving emergency department allowing them to fine-tune the make-up of the trauma team, prepare blood products and begin the process of creating bed capacity and readying the operating room. On-scene audio-visual feeds from EMS bodycams or overhead drone footage could provide vital information not easily communicated in a standard verbal handover. Police forces around the UK and elsewhere have been using real-time drone footage for a number of years to assist in searches and crowd management operations and we further highlighted the current and future capabilities of medical drones in the March edition of this blog.  Larger drones may even be used to expedite patient transport, especially from remote areas or when road transport would lead to delays.

 With significant life-threatening injuries identified prior to arrival, a targeted primary survey will facilitate rapid transfer of the patient to the imaging suite where static anatomical displays will be augmented with dynamic organ functional imaging to provide unprecedented cellular-level detail of organ dysfunction and hone in on specific bleeding points and the best surgical targets for haemostasis. Ultra-high-resolution 3D images of the scan will quickly be distributed amongst the surgical team to start planning their approach as well as providing a basic blueprint for the dimensions of any replacement organs that may need to be bioprinted at a later date. Recent breakthroughs in bioengineering allowing the printing of intricate vascular tissue beds herald the way for the  rapid mass production of organs on-demand and without the often-tricky issue of having to approach recently bereaved relatives to seek permission to harvest the organs of their loved one.

 In the next article we look at the crossover of advanced imaging into the operating room of 2050 where nanotechnology complements surgical hands and the continuum of care through ICU to rehabilitation is tailored to specific patient needs.

 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.

@drnnajiuba