Some people say trauma surgeons are born, not trained. I’m not so sure. You can learn to be a trauma surgeon — but it’s something you have to have a particular personality for.
In most typical surgery you generally know what you’re going to find. In trauma the converse is true — most of the time you don’t know. Some surgeons find that exciting — and that’s what makes a good trauma surgeon… the ability to go into something where you don’t know what you’ll find.
The Golden Hour concept is a little outdated, but its true that the first hour of a patient’s time in hospital is the most important hour — you have to get on top of things as quick as you can. With really badly injured patients you only have one shot to get things right — you have to do everything right and do it in the right order. If you make any mistake then you can have a significantly worse outcome.
It’s getting easier with rapid access to CT scan [which give clear images of the inside of your body] but often patients are not well enough to go to CT scan. So there is a detective element to it. And if you have a high-functioning team they work at the same time getting things done. That depends on where you work.
There’s a small number of mature trauma centres in this country where you do have a highly functioning team with a number of years behind them. But there are a number of teams that are in their infancy, so Gary Boyle would be struggling against some of the problems you see in the show. The common perception is that operating is difficult. Some operations are difficult — but the most important part is the decision making and the systems you have in place to act on those decision. There’s often diagnostic dilemma. Even the decision as to whether you operate on the abdomen or the chest…
But we do have fixed structure — the checklist is CABCD. C — Catastrophic haemorrhage, A — Airway, B — Breathing, C — Circulation (with haemorrhage control), D — Disability and you go on. You have to stop any catastrophic haemorrhage, then check the airway and so on. That’s the primary survey to make sure we don’t miss anything.
We are able to save lives of people who wouldn’t have survived ten years ago because our knowledge of blood has improved in the last ten years. We’ve restructured resuscitation. The old system was to give them IV fluids. That, in fact, makes things worse. So now we give blood as soon as we can. And we keep blood pressure slightly low to keep the clotting system in the best possible state.
There will be oddly motionless times— for instance if I have to open the abdomen and stop serious bleeding you pack the abdomen, like you see in episode one. You do that because that person is bleeding but you don’t know where from, so you push the cloth packs in to apply pressure and then leave the anesthetist to get the blood pressure and vital signs to catch up. That’s not going to solve the situation, but it will allow time to get more blood into the patient.
The other time is when you have someone who has had a heart attack because of loss of blood — there’s nothing wrong with that heart so you can fill the person up with blood again and sometimes the heart will start beating on its own. So you’re standing there looking at a patient who’s heart isn’t beating and it feels slightly strange…
The whole thing in trauma is to keep the brain tissues alive. Get things stable then work out where the bleeding is. Some surgeons like it, some surgeons don’t. It suits me.
Mr Gary Maytham is a consultant in vascular surgery at St George’s Hospital in south London
As told to Stephen Armstrong
Critical begins on Tuesday 24th February on Sky1 at 9pm