Hospital trauma units under threat

by Melanie Gosling

Radical changes to the treatment of emergency patients in the Western Cape will damage the province’s world-class trauma centres and compromise patient care, doctors say.

The provincial Health Department’s plan is designed to merge the overloaded casualty sections at tertiary hospitals with the smaller, highly efficient trauma units.

But doctors have described the proposal as “completely bizarre”.

There is “no doubt” this will compromise trauma patient care, they say.

But provincial health authorities deny this.

Currently Groote Schuur, Red Cross and Tygerberg all have dedicated trauma units to deal with complex trauma cases that need highly specialised treatment.

These include serious motor vehicle accidents, assaults, stabbings and gunshot wounds.

Groote Schuur’s trauma unit treated just under 11 000 patients last year, of whom 4 092 had been seriously assaulted, 2 200 had been in motor vehicle accidents and 580 came in with gunshot wounds.

Having a specialised trauma unit increases the patient survival rate by between 20 percent and 30 percent.

Other emergencies, ranging from heart attacks to pneumonia, asthma and diabetes, are seen at Groote Schuur’s casualty department, which treats about 3 000 patients a month.

Trauma cases are increasing in South Africa, where the trauma rate is the second highest in the world after Colombia, and doctors say trauma is on a par with HIV as a killer.

Professor Ken Boffard, president of the Trauma Society of South Africa, has written to the Western Cape Department of Health to say: “I would strongly advise that the decision to merge the emergency department and the trauma unit at GrooteSchuurHospital be very carefully reconsidered, with much wider consultation.”

Boffard said it had been shown nationally and internationally that where a dedicated trauma unit existed, the mortality rate was “substantially lower than even the large general academic hospitals”.

Professor Del Khan, head of surgery at Groote Schuur, said while he fully supported the establishment of central emergency medical facilities at secondary and smaller hospitals, this centralised system “has no place in major tertiary hospitals where we have well-established trauma units”.

“Trauma has reached epidemic proportions in the Western Cape. The trauma load is massive: motor vehicle accidents, violence, assaults, gunshots. Sometimes you go in there on a Monday and it looks like a war zone,” Khan said.

Rather than try to bring the highly-efficient trauma units of tertiary hospitals into a central system, and compromise their efficacy, the authorities should increase resources to the creaking casualty section.

“The real problem is the medical emergency side which has been overwhelmed with the workload. The only thing needed at Groote Schuur’s emergency unit is to increase resources,” Khan said.

The provincial health authorities have insisted that their proposal does not mean a merger of casualty and trauma units, but a “re-organisation of hospital emergency services”.

They say they plan to develop a “more integrated way of managing emergency services” with one emergency centre at tertiary and secondary hospitals, with specialised units attached.

Beth Engelbrecht, deputy director-general of of the Western Cape Health Department, said emergency services were “too fragmented”.

“There is no one in charge. I have travelled in ambulances to get some sense of what is going on,” Engelbrecht said.

“We’ve got trained nurses not doing anything (in trauma) but in general emergency the nurses are overstrained. In one part they are playing computer games and in the other one are long queues. Patients are waiting hours on end in casualty,” Engelbrecht said.

Engelbrecht said the trauma unit would be “positioned alongside” the emergency centre. Patients would be referred from the central emergency centre to the trauma centre. No extra staff would be hired.

Doctors say this is a return to the inefficient pre-1980 system.

“The two sections, casualty and trauma, were amalgamated in the old days and it was a disaster,” said one doctor, who did not want to be identified.

“They could not cope. They had patients like diabetics and asthma cases and then a gunshot chest. You can’t work like that. That’s why the two split. You need to be geared up for trauma with a team that is fresh and available 24 hours. Now they’re trying to undo the specialised trauma system, when the real problem is that they have slashed the beds in casualty.”

Khan said trauma surgeons could train only at institutions accredited by the Health Professions Council of SA. Groote Schuur’s trauma unit was in the process of being given accreditation.

“If we go down the route they (provincial authorities) want, we won’t get accreditation and we won’t be able to train trauma surgeons at Groote Schuur,” Khan said.

Groote Schuur’s trauma unit is internationally recognised and has a patient survival rate on a par with the most developed countries.

Doctors from the UK and Europe came to work at the unit for six moths or a year to learn from South Africa how to manage trauma.

“The UK is now going down the road of having trauma units like ours and Professor Andy Nicol, the head of Groote Schuur’s trauma unit, has been asked to go to the UK to tell them how it’s done here,” Khan said.

The centralisation of emergency services will happen only in the Western Cape.