We read with disappointment and some alarm the article entitled
‘Investigation of Blunt Abdominal Trauma” by Jansen et. al. (1). The
article purports to be an evidence based meta-analysis of the imaging
literature whose purpose is to provide guidance regarding imaging
investigations in patients with blunt abdominal trauma. In fact the
proposed algorithm reiterates and perpetuates old dogma (2). In our
opinion this contributes to the UK having an excess trauma death rate
compared to most developed countries.
The authors have missed the opportunity to highlight why and how
trauma services need to improve. It is essential for the medical
profession to recognise the need to change and to provide politicians with
good medical advice if they are to resource, organise and validate trauma
services. The incidence of major trauma in the United Kingdom is
relatively low and in the absence of coordinated trauma service provision
the NHS response is often enthusiastic but disorganised. Perhaps these are
factors that explain the lack of any obvious political will to improve
trauma services at the expense of other obvious vote catching health
issues like cancer and heart disease.
One third of the 9,000 - 11,000 trauma deaths in the UK each year are
considered to be entirely avoidable (3). A significant proportion of
patients will be left with long term disability. Tragically most of the
victims are young and economically active. This situation has not altered
or improved since the late 1980’s and given all the advances there have
been
in our understanding of trauma and in training one has to ask why this is?
Firstly the clinical response services must be organised from the top
down. It is a shame that the authors have missed the point when quoting
statistics from the NCEPOD report “Trauma Who Cares”(4) regarding the
number of junior doctors who are first attenders at polytrauma cases. It
was not calling for better education –that is taken as read. It was
calling for a more experienced first response! Fortunately the military
and freelance journalists appreciate this essential point (5).
The authors have also misunderstood some of the key findings and
recommendations of the above report and ignored modern literature which
suggests that “CT is vital to the investigation and subsequent management
of polytrauma patients” or that “therapeutic interventional radiology (IR)
techniques have now become essential in the management of severely injured
patients” (6). Their algorithm suggests CT for stable patients only and
fails to explore recent widespread developments in mutidetector CT and
resuscitation facilities that puts CT at the heart of the secondary
survey. Such rapid head to toe multidetector scanning is now being used in
Europe, North America and Australia to define the nature and extent of
injuries and signpost those which are imminently life threatening. Only in
this way can they be directed to the most appropriate therapy. Hence,
early CT scanning in the right environment should be the norm for the
majority of patients with severe trauma. This would render obsolete less
accurate tests such as diagnostic peritoneal lavage (7)
This article fails to ask why the development of trauma imaging and
intervention in the UK is so far behind the rest of the world. CT’s
reputation as the “doughnut of death” relates to old technology and bad
planning. In modern trauma centres CT and angiography facilities are part
of resuscitation rooms and designed to be patient and resuscitation
friendly.
We are afraid that the publication of this ill thought out and
inadequate review of a tired much repeated literature will help to
perpetuate the unacceptably high death rate amongst young trauma victims.
An opportunity to improve and look to the future has been badly missed.
1. Jansen JO, Yule SR, Udon MA. Investigation of Blunt Abdominal
Trauma; BMJ 2008;336: 9382-942
2. Beckingham, I J et al. ABC of diseases of liver, pancreas, and
biliary system: Liver and pancreatic trauma. BMJ 2001;322:783-785
3. Better Care for the Severely injured. A Report from The Royal
College of Surgeons of England and the British Orthopaedic Association
2000 & 2003 www.rcseng.ac.uk & www.boa.ac.uk
4. Trauma : Who Cares. NCEPOD 2007
5. Gulland A Lessons from the battlefield BMJ 2008;336:1098-1100
6. Pryor J, Braslow B, Reilly P, et.al. The evolving role of
interventional radiology in trauma care, Journal of Trauma-Injury
Infection & Critical Care 2005; 59:102-104.
7. Watson NFS, Hammond JS, Brooks A, Abercrombie JF, Maxwell-
Armstrong CA. Blunt abdominal trauma: Note of caution on diagnostic
peritoneal lavage. BMJ 2008;336:1086
Rapid Response:
‘Investigation of Blunt Abdominal Trauma”
Dear Editor,
We read with disappointment and some alarm the article entitled ‘Investigation of Blunt Abdominal Trauma” by Jansen et. al. (1). The article purports to be an evidence based meta-analysis of the imaging literature whose purpose is to provide guidance regarding imaging investigations in patients with blunt abdominal trauma. In fact the proposed algorithm reiterates and perpetuates old dogma (2). In our opinion this contributes to the UK having an excess trauma death rate compared to most developed countries.
The authors have missed the opportunity to highlight why and how trauma services need to improve. It is essential for the medical profession to recognise the need to change and to provide politicians with good medical advice if they are to resource, organise and validate trauma services. The incidence of major trauma in the United Kingdom is relatively low and in the absence of coordinated trauma service provision the NHS response is often enthusiastic but disorganised. Perhaps these are factors that explain the lack of any obvious political will to improve trauma services at the expense of other obvious vote catching health issues like cancer and heart disease.
One third of the 9,000 - 11,000 trauma deaths in the UK each year are considered to be entirely avoidable (3). A significant proportion of patients will be left with long term disability. Tragically most of the victims are young and economically active. This situation has not altered or improved since the late 1980’s and given all the advances there have been in our understanding of trauma and in training one has to ask why this is?
Firstly the clinical response services must be organised from the top down. It is a shame that the authors have missed the point when quoting statistics from the NCEPOD report “Trauma Who Cares”(4) regarding the number of junior doctors who are first attenders at polytrauma cases. It was not calling for better education –that is taken as read. It was calling for a more experienced first response! Fortunately the military and freelance journalists appreciate this essential point (5).
The authors have also misunderstood some of the key findings and recommendations of the above report and ignored modern literature which suggests that “CT is vital to the investigation and subsequent management of polytrauma patients” or that “therapeutic interventional radiology (IR) techniques have now become essential in the management of severely injured patients” (6). Their algorithm suggests CT for stable patients only and fails to explore recent widespread developments in mutidetector CT and resuscitation facilities that puts CT at the heart of the secondary survey. Such rapid head to toe multidetector scanning is now being used in Europe, North America and Australia to define the nature and extent of injuries and signpost those which are imminently life threatening. Only in this way can they be directed to the most appropriate therapy. Hence, early CT scanning in the right environment should be the norm for the majority of patients with severe trauma. This would render obsolete less accurate tests such as diagnostic peritoneal lavage (7)
This article fails to ask why the development of trauma imaging and intervention in the UK is so far behind the rest of the world. CT’s reputation as the “doughnut of death” relates to old technology and bad planning. In modern trauma centres CT and angiography facilities are part of resuscitation rooms and designed to be patient and resuscitation friendly.
We are afraid that the publication of this ill thought out and inadequate review of a tired much repeated literature will help to perpetuate the unacceptably high death rate amongst young trauma victims. An opportunity to improve and look to the future has been badly missed.
1. Jansen JO, Yule SR, Udon MA. Investigation of Blunt Abdominal Trauma; BMJ 2008;336: 9382-942
2. Beckingham, I J et al. ABC of diseases of liver, pancreas, and biliary system: Liver and pancreatic trauma. BMJ 2001;322:783-785
3. Better Care for the Severely injured. A Report from The Royal College of Surgeons of England and the British Orthopaedic Association 2000 & 2003 www.rcseng.ac.uk & www.boa.ac.uk
4. Trauma : Who Cares. NCEPOD 2007
5. Gulland A Lessons from the battlefield BMJ 2008;336:1098-1100
6. Pryor J, Braslow B, Reilly P, et.al. The evolving role of interventional radiology in trauma care, Journal of Trauma-Injury Infection & Critical Care 2005; 59:102-104.
7. Watson NFS, Hammond JS, Brooks A, Abercrombie JF, Maxwell- Armstrong CA. Blunt abdominal trauma: Note of caution on diagnostic peritoneal lavage. BMJ 2008;336:1086
Yours faithfully
Competing interests: None declared
Competing interests: No competing interests