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Joy & Sorrow in
Trauma Training
CW Kam Chairman, Trauma Advisory Committee
Director, CSTC
Cons, TMH AED
NTWC
HA Convention 2018
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We share, we learn ..
& we grow up together for our patients & their families ….
Kam CW 2009 Trauma Sym
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Mission – Traumatology
Training Staff
Helping Patients
Saving Lives Traumatology Education
↑ Outcome of the casualties
↓ Preventable Mortality
↓ reduce morbidity
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Lethal Triad ↑ with Delay
Bloody Vicious Cycle
Hypothermia Acidosis
Coagulopathy
Damage Control Resus
To prevent Lethal Triad of Trauma
Acidosis
Coagulopathy
Hypothermia
By D C Rx
Permissive Hypotension
Hemostatic Resuscitation - MTP
DCS (Damage Control Surgery / Ops)
Restore physiology before total anatomical correction
Ref. Jansen JO. BMJ 2009.
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Mortality Reduction in Battles
by DCS + Bundle of Changes
Ref : Holcomb JB. The 2004 Fitts Lecture: Current perspective on combat casualty care. J Trauma 2005;59:990-1002.
Wars Vietnam
1961-1973
Gulf
1990-1991
Iraq
2003
Afghanistan
2009
Mortality
-US Wounded
Servicemen
24%
10 %
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Hong Kong Features
an Advanced but Aging City
High Safety + Peaceful
Predominant healthcare focus Cancer
CVS / CVA / Chest Infection
Degenerative Diseases
Recurrent Annual Flu Surge
Traumatology - a neglected
“No Man’s Land of Non-specialty”
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HK Death Stat 2015
Birth 59,900 HK Vital Stats 2015 Pop = 7.2M
MVC 110 5.5
Death 46,757 100% Fall 327 16.4
Cancer
13,139 28.10% Drowning 48 2.4
CVA ? ? Fire 10 0.5
Resp
7,762 16.60% Poison 138 6.9
External
(1,993) 5.60% DSH 991 49.7
Assault 22 1.1
All - Ext 1993 100.0 17
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Trauma
Competitors Vs Companions
Antagonistic / Complementary
A) Cancer Diseases
B) Calculous Dis
C) Infectious Dis
D) CVS / Stroke
E) Deg Diseases / Aging F) Others
Traumatology Training
Challenges
Shrinking Volume %
Clinical Exposure ↓
Expertise Diluted – other
Subsp ↑
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HK Trauma Epidemiology
Volume burden - not high enough to
justify full or large scale teams
Pat Pn time ~ irregular to attract the
clinicians to dedicate the whole career life
Lack of private practice option
Most man-power is dedicated to services
very scarce resources - training
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Outcome-based Model of
Learning & Training
Knowledge, Skills, Attitude,
Action / Behaviour Change to translate to
bed-side Clinical Assessment & Intervention to
identify the injuries
to treat the obstructed airway, hypoventilation,
to stop the bleeding
to rescue the brain & limb functions
according to the life-saving priority sequence.
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Kirkpatrick’s Model of
Training Evaluation
Pat Outcome & Money Saving ?
Level
5
Return on
Investment
Was the training worth the cost ?
Invest to SAVE ?
4 Results
Did the change in behaviour positively affect the
organization ? Patient outcome ?
Multivariate Logistic Regress Analysis
3 Behaviour /
Training
Transfer
Did the participants change their behaviour on
the job based on what they learned ?
2 Learning
What S / K / Attitude changed after training ?
By how much ?
1 Reaction Did the participants like the training ?
What do they plan to do with what they learned ?
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Trauma Training Formats
Lecture Mass Edu Efficient↑ Effective↓
Knowledge Foundation
Depressed GCS 13 – 14
Tutorial Small Gp / more $ In-depth reasoning /
Blind Spots Rx
Hands-on Animal
Tissue Procedures /
Task Trainers
Expensive
High Trainer to Std
Ratio
Better understanding +
Higher Retention
Simulation $$$$$ /
Laborious
Comm / Team Work /
Conflict Mx / Risk Dx &
Rx / Debriefing
Computer-based
Modular Learning
Expensive
Multi-facet / Format
Individualised Needs &
Learning Pace
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Tourniquet – How to apply ?
Save life then limb & the functions
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Hemorrhage Control Device to Any Convenient Bandage
Hyperlink – Tourniquet application video >>
Torniquet_5_Paramedic_Sofa_Title_1m57s.wmv
Tourniquet – Major Limb Bleeding
Past Medical Taboo
>> Now Life Saving
Military / AE – Limited Resources
● Hemorrhage control – HAT (Hemostatic Arterial Tourniquet)
● Basic Principles – ABCDE
● ATLS – from City to Rural
Massive Wounds from Explosions
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Trauma Simulation Training Each Scenario – 4 to 6 stds
• Overall Satisfaction:
– 8.97
• Competence:
– 6.58 -> 8.24
TMH Trauma Team – Pat AssessM
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Non-Responder (RED Signal)
1. Check for Tn PTX & Pericardial Tamponade
2. Em OT Access – to STOP External & Internal Bleeding
3. MTP
4. CT Imaging is contra-indicated By CW Kam / John Wong - CTAC, TMH 15 Mar 2017
TMH Trauma Team – Pat AssessM
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Transient Responder
1. Check for External & Internal Bleeding (PE + XR + USG ) 2. CT Imaging – cautious consideration 3. MTP 4. Urgent OT Access – to STOP External & Internal Bleeding By CW Kam / John Wong - CTAC, TMH 15 Mar 2017
TMH Trauma Team – Pat AssessM
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Rapid Responder
1. Thorough PE 2. AMPLE Hx 3. Ix – Blood / Urine / XR / USG 4. CT Imaging – Safe & Useful 5. MTP – not likely 6. OT Need – depends on clinical progress & CT findings ( check Verbal /
Prelim CT Report to expedite Rx Plan ) By CW Kam / John Wong - CTAC, TMH 15 Mar 2017
Structured Team +
Organized Communication
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不怕神 一樣的對手 😇
只怕豬 🐷🐽 一樣的朋友
God-liked Enemy is not lethal
But Piggy Friend can Kill
Team Work
Communication
Multi-tasking
Management Priority
1. Briefing + Time Out
2. Closed-Loop Communication
3. Read back 4. Debriefing
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Traumatology Motivation
• Difficult / Tough Task
• Unpleasant & Stressful Work
• Bleeding Pathology
• Higher M&M – Polytrauma
• Open Surg Vs Current MISurg
• Irregular Work Hours
• Unsocial Life
• Lack of Private Practice
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Traumatology
Trainee Motivation
HA Service Need –
Senior Support
+ Monitor
Protected Training
Time
College Training Rqm Abundant Training
Events
Virtue - Life Rescue Role Modelling
High-end Intellect /
Skills
Learning + FUN
+ International
Exchange 70
Traumatology Role Models
• Dynamic Model - Shock Response to Fluid Resus
• Critical Care / Trauma Ward to monitor
• Dedicated Unit / Traumatologists to closely reassess Pat
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AM
Session
PM
Session
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Welcome to Hon. Delegates of
Ulsan U Hosp & Trauma Centre of Korea
Mutual Enlightenment - Traumatology
Traumatology
TRAINER Motivation
Service Sustainability
HA Service
Need – Trainer
as Leader
Funds to
improve
equipment /
facilities
Career
Advancement
Rotation – 3 to 5
Service Yrs
Burnt-out Prevention 77
Trauma Nurse Consultant Privileges + Responsibility
1) To support the Trauma Medical Director / Trauma Committee Chairman to direct & support Critical & Acute Polytrauma Trauma Care
2) To provide timely Interdept Liaison to sustain & improve high quality Polytrauma Mx Services
3) To guide the Frontline Trauma Nurses to acquire proficient Trauma Mx Skills & Interdept Communications
4) To enhance the current Trauma Database & Audit System – higher frequency & to expedite the implementation of improvement measures
5) To upgrade the Post-Admission Integrated Trauma Patient Mx Plan to improve the Outcome & to shorten the LOS
6) To set up training strategy to escalate the Trauma Skills of the General Trauma & Subspecialty Clinical Nurses to prepare the future establishment of Trauma HDU
7) To provide Regular Community Injury Prevention Programme in collaboration with other Government & NGO bodies
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Trauma Comm Chairman
& Trauma Prog Director
Comm
Policy & Direction
Monitoring & Audit
Staff Training
Trauma Director
Daily Trauma Services – Trauma Beds / HDU
Interdepartmental liaison
Surgical Skills Training
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Traumatology
Dilemma
Mega
Centres
• More Severe
Injuries
• Unsafe City
Effective
Prevention
• Diminishing
Injuries
• Vanishing Trauma
Services 82
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Level I Trauma Centre –
ATS / ACS
Level I Trauma Center - comprehensive regional resource / tertiary care facility / total care for every aspect of injury –
from Prevention, Acute Rx through Rehabilitation
Elements of Level I Trauma Centers Include: ……..
Kam’s Philosophy 2007 - Traumatology
Prevention – Non-attractive & High NNT
Rescue – High Profile / Sexy Superman
Definite Rx : Operation
Best Rx : Prevention Trauma Prophylactic
Anti-dote
Crushed Hand 無法修飾的一對手
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曲突徙薪無恩澤 😭
焦頭爛額為上客
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Kam’s Philosophy
– Trauma Mx
The Dead is not salvageable
Definite Rx
Operation
Best Rx :
Prevention Trauma Prophylactic
Anti-dote
Decapitation
Traumatology
Services & Training
Situation + You & Your Input
Difficult Optimistic
Under-resourced
Unstinting Support
Neglected Proficient Rx
Frequent Sorrow
Effective Prevention – Suffering Reduction
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Thank you for your kind attention
GCS 16 . Not falling Asleep ..
~
Tuen Mun Hospital
Hong Kong
Walking ~ Journey – Traumatology & Prevention
KOL = Kings of Like
Or -- Key Opinion Leaders
to Maximize Injury Pat Outcome