Dhanupriya Sivapathasuntharam is Lead Clinician for Trauma and Perioperative Older Person’s Services at the Royal London Hospital. She Tweets as @DhanupriyaSiva. Mark Baxter is a Major Trauma Geriatrician and Director of Major Trauma at University Hospital Southampton NHS Foundation Trust and Tweets at @Bbdoc3.
Historically, the phrase ‘major trauma’ conjures up images of road traffic collisions, terrorist attacks or penetrating injuries.
However, with an ageing population, the nature of ‘major trauma’ patients has changed both nationally and internationally with a move from younger men to older patients, most commonly older women.
The mechanism of injury is different in older trauma, with a fall from less than 2 metres being the commonest mechanism of injury in older patients rather than road traffic collisions which are more common in younger patients.
The organisation of trauma care has changed radically over the last 15 years with the development of regional trauma networks with designated specialist Major Trauma Centres and trauma units alongside advances in pre-hospital care. However, the different mechanisms of injury in older patients continue to lead to delays in diagnosis, with many older patients less likely to be transferred to their regional Major Trauma Centre (MTC) than their younger counterparts.
One of the reasons for this is that prehospital triage is not yet robust enough to correctly differentiate those patients who have sustained injuries that would constitute major trauma amongst those many patients who sustain falls from standing height without significant injury or with only an isolated injury.
These findings were published in the Trauma Audit and Research Network report of 2017, which highlighted some of the ongoing challenges in this complex patient group. They found that older patients were much less likely to be transferred for specialist care and more likely to have longer times for both investigation and treatment, including surgery. In addition, they were more likely to be seen by a more junior doctor than younger patients, delaying senior decision making. Unsurprisingly, this group of patients had a high mortality. However, in those patients who do survive, they did not have a greater disability compared to younger people. Traumatic Brain Injury was found to be the commonest injury.
Nevertheless, the number of older people admitted under major trauma services does continue to rise, and the patients are increasingly complex and co-morbid. Following on from the success of orthogeriatricians in hip fracture care, it seems essential that this group of patients should also receive input from our speciality. This has been standard practice at both our and other MTCs for several years now and we have noted the positive benefit for these complex patients, many of whom suffer from frailty, that comes from the experience of a geriatrician supporting the trauma team.
In order to further increase geriatrician input across the country and incentivise organisations to invest in Major Trauma Geriatricians and building on from the success of the best practice tariff initiatives in hip fractures, a Best Practice Tariff for Major Older Trauma was introduced in April 2019. This requires that all patients with an Injury Severity Score (a retrospective score calculated by assessing all the injuries a patient sustains) of more than 15 should be seen by an ST3 or above geriatrician within 72 hours of admission or extubation. This has led to more Trusts taking note of this group of patients, and expansion in consultant geriatrician numbers.
Acknowledging the complexity of managing these patients e.g. when to anticoagulate after head injury or collar and brace use in spinal fractures, many of us in the subspeciality communicate with each other and there have been two National Meetings over the last few years where ideas were exchanged and complex scenarios discussed. Most of us worked at Major Trauma Centres, but there is a need for geriatricians with a specialist interest in these patients at Trauma Units as well, as it may be better to design pathways of care in the future that offer interventions closer to home. In addition, as injuries are missed because suspicion of multiple injury can be low, it is important for all physicians to be aware of the scale of the problem.
At the BGS Spring Meeting in April 2021, a whole day was dedicated to Major Trauma and this received very positive feedback.
As the next step from this, it was felt that there was sufficient interest to start a Major Trauma Special Interest Group (SIG). Initially we asked for expressions of interest and we have already nearly 80 people who have come forward. We will need more to make it an official SIG and it will have to be approved by the BGS Trustee Board, however we are confident there is a lot of interest as this is an exciting and expanding field of practice with lots of scope for training and research.
If you would like to join this group and have not already done so, please contact Jo Gough at j.gough@bgs.org.uk.
We hope to welcome more people to this group and to see more people joining our sessions at the BGS conferences in the future.
