Trauma: Is this the future of casualty departments?

The Royal London Hospital has one of the most advanced and successful trauma units in Britain. Jeremy Laurance spends a day on the front line

(David Sandison)

As we climbed the last steps to the roof of the Royal London Hospital, the helicopter ambulance clattered noisily into the air, its scarlet livery vivid against a gunmetal sky. “Multiple stabbing, Croydon,” announced Anne Weaver, consultant in A&E medicine, as she greeted us on the landing pad, an icy wind whipping the hair across her face. It would take the team – an experienced trauma doctor and a paramedic, plus the pilot – about nine minutes to reach the victim, she said.

This was both bad and good news. Bad news, obviously, for the victim. Stabbings and shootings have been increasing in the capital over the past decade, as is well known, and the number arriving at the Royal London has risen still faster, from 15 to 23 per cent of all trauma calls.

The reason, and this is the good news, is that ambulance crews know the victims have a better chance of survival here than almost anywhere. The Royal London, in Whitechapel, has the only major trauma unit in the capital, with specialist teams, state-of-the-art equipment – and a helicopter ambulance. Death rates for severely injured patients are 28 per cent lower than the national average. Now London is to get three more major trauma units, under plans announced last month. It is not just about speed, though that is critical; it is about skill, too.

Snow flurries were blowing around the landing pad and we withdrew to the warm fug of the operations room to await the helicopter’s return. A radio crackled into life. “Medic 1, come in please” said a voice. The request was met with silence.

Saving the life of someone who has been stabbed through the heart is simple, though difficult, according to Dr Weaver. You put your thumb over the hole in the heart, hold it there until you can get the victim to hospital, and hope. That’s it. First, of course, you have to open the chest, a procedure called a thoracotomy. Doctors from the Helicopter Emergency Medical Service do about 35 thoracotomies a year – in parks or by the roadside – and patients have an 18 per cent survival rate after the procedure. About six of the 35 live.

It may not sound much until you consider that these patients are already in cardiac arrest before the doctors start work on them. It would be more accurate to say that the six are brought back from the dead.

In the control room, the radio stutters noisily into life. “Medic 1, come in”. The only sound at the other end is the hiss of static.

With a population of 20 million inside the M25, and 4,500 calls a day to the London Ambulance Service, the helicopter crew have to know where to find the most seriously injured patients. To help them, a paramedic sits at the London Ambulance HQ combing through the 999 calls – and listening in as they are made, where necessary – for the signals that will press the scramble button.

To help the paramedic, there is a list of criteria: falls from two floors or above, car accidents where a person has been flung from the vehicle, a person under a vehicle or under a train. Any one of these can trigger a helicopter call out.

But making the judgement about what is and is not a life-threatening situation can be difficult. Dr Weaver recalls an incident that still gives her nightmares – an eight-year-old boy who had a row with his mum, ran out of the room and into a plate glass window, severing an artery in his arm.

“The mother had screamed at her neighbour to make the 999 call while she tended to her son. But the neighbour didn’t know what was happening. The operator could hear a child crying and assumed it was not too serious. But the crying child was a sibling; the injured child was comatose on the floor bleeding to death.”

On that occasion, help arrived in time and the boy’s life was saved. But the line between tragedy and victory is alarmingly fine.

The radio crackles again. Medic 1 is finally on the line. The “multiple stabbing” victim has turned out to be a disturbed young man who has slashed himself across the chest with a knife. His wounds are superficial and it has been agreed that a local ambulance crew will take him to the nearest A&E.

Ten minutes later, the helicopter is back on its pad and the crestfallen emergency doctor, Gareth Davies, steps out in his orange flying suit. He has been with the emergency service for more than a decade and though wasted trips like today’s are frustrating, he is committed to trauma medicine. It is an antidote to the routine of the ward round. “It is quite difficult to do a lot for most patients. Here we can move heaven and earth to save them. That is quite addictive.”

Back at ground level, Mike Walsh, Consultant Vascular and Trauma Surgeon, is chatting with a doctor in the trauma ward as gangs of hooded youths squeeze by, looking for their stitched and bandaged friends. This is London’s only ward devoted to the seriously injured – victims of falls, car accidents, stabbings, shootings – and one of the few with specialist trauma surgeons.

“Most hospitals see one seriously injured person a week or a month. Here, we average three or four a day. The more you do, the better you become. It is about critical mass. We have five seriously injured patients in intensive care at any one time. Most other hospitals might have one,” he says.

Square shouldered, taciturn, with a passion for fast cars, Walsh is like an older version of Bond star Daniel Craig. He cut his teeth as an emergency surgeon at the main hospital in Windhoek, the capital of Namibia, where they once saw 121 stabbings in a single night. One of his first operations was on a man stabbed in the heart and when he sewed him up successfully and his heart was beating a cheer went up around the operating table.

He has been at the Royal London for almost 10 years and seen the death rate of the most severely injured victims fall by more than a quarter in that time. How has he done it? By checking the outcome of cases and looking to see what could have been done better. Of around 30 hospitals with A&E units in London, the Royal London was the only one to submit full data to the recent Trauma Audit and Research Network. “Most hospitals don’t know what their outcomes are,” he said.

Now the model established by the Royal London – specialist trauma teams, critical mass, measuring outcomes – is being rolled out across the capital. Three more major trauma units at St George’s Hospital, Tooting, King’s College Hospital, Camberwell and St Mary’s Hospital, Paddington are proposed in a consultation document published last month by NHS London. Seriously injured patients would bypass their local A&E and go straight to one of these units with a maximum “blue light” journey time of 45 minutes from anywhere in London, the document says.

The plan will worry those who believe their best hope of survival in an accident lies with getting rapidly to the nearest A&E. But Walsh is adamant. “It is not about travel times – it is about the time to definitive care. You can get to A&E with a head injury and then wait hours for a transfer to a neurosurgical unit. It’s about organisation, not location.”

He recalls an incident from 20 years ago when he was a surgical trainee at an outer London hospital and one of the nurses was brought in with a serious head injury from a cycling accident. “Her care was a complete shambles. I thought: is this the best we can do? For one of our own nurses? It took five hours to find a neurosurgical unit to take her – and that is still happening 20 years later. It is time to definitive care that counts.”

There are likely to be protests from some hospitals who will want to know what their A&E units will lose in order that the new trauma units may thrive. But Walsh insists there could be gains all round.

In the Netherlands, where a national trauma service was established 10 years ago, the improvement in survival that followed was greatest in the hospitals taking the less severe injuries. By setting standards and following protocols, the quality of care was raised across the board. The smaller units raised their game more than the bigger ones.

“I won’t be satisfied until I know that if you are injured in the UK, wherever you are taken you will get the best care. We are a long way off that now,” he says.