An observational study evaluating the demand of major trauma on different surgical specialities in a UK Major Trauma Centre

Brain drain in Emergency Medicine in Lebanon, building locally and exporting globally

OBJECTIVE

Despite the growth of Emergency Medicine (EM) globally, shortages of EM-trained physicians persist in many countries, disproportionately affecting lower middle/low-income countries (LMIC/LIC). This study examines the career paths of graduates of an Emergency Medicine residency-training program established in Lebanon with the aim of building local capacity in EM.

DESIGN AND PATIENTS

This descriptive study utilizes secondary data sourced from an alumni database that includes nine cohorts of graduates from an Emergency Medicine residency program at the American University of Beirut Medical Center in Lebanon.

MEASUREMENTS AND MAIN RESULTS

Within 12 years since the EM residency program establishment a total of 9 cohorts, including 44 physicians had completed their residency training in EM, with 40.9% being female and 95.5% Lebanese citizens. After graduation, almost half of our graduates (47.7%) enrolled in fellowship training programs and 40.9% joined the workforce. Fellowships in Trauma (19%) and Oncologic Emergencies (19%) were the most commonly pursued. Initial employment destinations predominantly included Lebanon, the United Arab Emirates and the Kingdom of Saudi Arabia, (61.1, 33.3 and 5.6% respectively). However, retention within the local market declined with time, with a median time spent in Lebanon of 1 year and a mean of 3.3 years of practice in Lebanon prior to emigration. Presently, graduates are mostly dispersed across the Gulf Cooperation Council region (38.6%), the USA (25%), and Lebanon (20.5%).

CONCLUSION

Building Emergency Medicine expertise to match the growing population needs for specialized acute care remains a challenge globally, especially in low-middle income and low-income countries. Our study highlights the challenge of retaining specialized medical graduates in LMIC. Understanding and addressing the root-causes of out-migration of highly specialized medical workforce is an essential component of addressing local workforce challenges that needs to be coupled with capacity building initiatives for meaningful impact.

Improvements over time for patients following liver trauma: A 17-year observational study

Background

Centralisation of trauma care has been shown to be associated with improved patient outcomes. The establishment of Major Trauma Centres (MTC) and networks in England in 2012 allowed for centralisation of trauma services and specialties including hepatobiliary surgery. We aimed to investigate the outcomes for patients with hepatic injury over the last 17 years at a large MTC in England in relation to the MTC status of the centre.

Methods

All patients who sustained liver trauma between 2005 and 2022 were identified using the Trauma Audit and Research Network database for a single MTC in the East Midlands. Mortality and complications were compared between patients before and after establishment of MTC status. Multivariable logistic regression models were used to determine the odds ratio (OR) and 95% confidence interval (95% CI) for complications according to MTC status, accounting for the potentially confounding variables of age, sex, severity of injuries and comorbidities for all patients, and the subgroup with severe liver trauma (AAST Grade IV and V).

Results

There were 600 patients; the median age was 33 (IQR 22-52) years and 406/600 (68%) were male. There were no significant differences in 90-day mortality or length of stay between the pre- and post-MTC patients. Multivariable logistic regression models showed both lower overall complications [OR 0.24 (95% CI 0.14, 0.39); p < 0.001] and lower liver-specific complications [OR 0.21 (95% CI 0.11, 0.39); p < 0.001] in the post-MTC period. This was also the case in the severe liver injury subgroup (p = 0.008 and p = 0.002 respectively).

Conclusions

Outcomes for liver trauma were superior in the post-MTC period even when adjusted for patient and injury characteristics. This was the case even though patients in this period were older with more comorbidities. These data support the centralisation of trauma services for those with liver injuries.

A profile of a major trauma centre of North West England between 2011 and 2018

This study examined the trends and patterns of major trauma (MT) activities, causes, mortality and survival at the Aintree Major Trauma Centre (MTC), Liverpool, between 2011 and 2018. The number of trauma team activations (TTAs) rose sharply over time (n = 699 in 2013; n = 1522 in 2018). The proportion of TTAs that involved MT patients decreased from 75.1% in 2013 to 67.4% in 2018. The leading cause of MT was a fall from less than 2 m (36%). There has been a fivefold increase in the overall number of trauma procedures between 2011 and 2018. Orthopaedic surgeons have performed 80% of operations (n = 7732), followed by neurosurgeons, oral and maxillofacial surgeons, and general trauma surgeons. Both types of fall (> 2 m and < 2 m) and road traffic accidents were the three leading causes of death during the study period. The observed mortality rates exceeded that of expected rates in years 2012, 2014, 2016 and 2017. The all-cause observed to expected mortality ratio was 1.08 between 2012 and 2018. A change in care for MT patients was not directly associated with improved survival, although the marginally ascending trend line in survival rates between 2012 and 2018 reflects a gradual positive change.

The impact of major trauma centre designation on routine orthopaedic trauma care

Introduction

Major Trauma networks were introduced in 2012 to improve care for patients with major traumatic injuries. Current evidence suggests that this has been successfully achieved, however, there are implications for ‘routine trauma care’ of patients who attend a major trauma centre.

Methods

We assessed time from injury to surgery in August to October in 2011 and 2019. We also assessed the National Hip Fracture Database outcomes for time to surgery for hip fracture patients.

Results

Average wait times for ankle surgery increased from 4.9 days (18 patients) in 2011 to 7.0 in days (26 patients) in 2019, whilst for distal radius fracture surgery increased from 3.9 days (36 patients) to 6.5 days (23 patients); the percentage of patients who received their hip fracture surgery within the recommended 36 hours was 53.7% in 2011 (322 patients) compared to 66.7% in 2019 (375 patients).

Conclusion

The wait times for ‘routine trauma care’ have increased since the introduction of the major trauma network. This is probably due to the large demand on major trauma centres presented by complex trauma patients. However, the number of patients undergoing hip fracture surgery within 36 hours has improved, probably driven by the NHS tariff for hip fracture care. Changes to the current major trauma system or an increase in resources are required to help reverse this trend.