“There is only one winner in warfare, and that is medicine,” Dr Rhys Thomas, a specialist anaesthetist and former Lieutenant Colonel in the British Forces, has told an anaesthetists conference being held in Wellington, November 5-7.
His presentation focused on the profound changes that lessons in Afghanistan have brought to resuscitation techniques now being used for civilians in the UK and elsewhere. Dr Thomas was speaking to the New Zealand Annual Scientific Meeting of the Australian and New Zealand College of Anaesthetists (ANZCA). Resuscitation and the management of blood loss in trauma cases are typically the role of anaesthetists.
“In Afghanistan, the high number of casualties led to us looking into what was happening to the physiology of those with severe trauma. Once we understood that, resuscitation techniques changed and we used blood and blood products along with injections of transexamic acid to stop bleeding.
“And rather than waiting for the patient to be brought to a hospital, we flew a consultant with those products to the patient in the war zone to provide this advanced resuscitation.
“This resulted in a dramatic improvement in the number of patients who could be brought back alive to a hospital where advanced work saw the overall mortality rate fall further. Between 2006 and the end of 2009, the use of massive transfusion techniques saw mortality drop to seven per cent compared with an expected mortality rate of 60 per cent for trauma cases back in the UK.”
“The hospital developed a Formula One-type of rapid blood resuscitation node with surgeons desperately trying to stem the source of bleeding while anaesthetists and nurses rapidly replaced the patient’s blood.
“However, our focus was not just on survival but on getting much better outcomes overall – getting patients well enough to be able to return to work. For instance, we could have double amputees back walking within six weeks.”
Achieving that requires each link in the chain to be as good as the other, so another change was adopting crew resource management (CRM) techniques learned from the aviation industry. These focus on managing large teams more effectively by improving communication and leadership in stressful situations.
Dr Thomas said the success of these techniques has seen them applied in the UK’s new trauma networks. He is the national clinical director of the emergency medical retrieval and transfer service in Wales, which replicates what was being done in Afghanistan.
“The helicopter and teams are smaller but the capability is the same. The service is based on the principle that enhanced care teams should be available 24/7 to provide care to the major trauma patient.
“Next year, this service will become available 24/7 (currently it is 12 hours a day) and any trauma case in Wales will be able to be reached by road or helicopter within 20 minutes, with medical staff equipped to provide that vital initial effective resuscitation.”
Patients are then transferred to hospitals staffed by trauma experts. As well as road and other accidents, the service handles medical cases, neonatal, paediatric, and critical care transfer and retrieval.