From: Cowley A, Durham M, Aldred D, Crabb R, Crouch P, Heywood A, McBride A, Williams J, Lyon R. (2019) ‘Presence of a pre-hospital enhanced care team reduces on scene time and improves triage compliance for stab trauma’. Scan J Trauma Res Emerg Med 27(86).
Penetrating trauma is on the rise, everywhere (Allen et al., 2019). Once the preserve of the hardened inner-city paramedic, it has crept out to every service in every area and can just as easily happen in the quaint village down the road, as the deserted back street behind a run-down metropolitan tower block.
Penetrating trauma is sly. It catches us at our most vulnerable; in the early hours of the night, swamping us with stimuli – darkness, flashing lights, crowds, adrenalised bystanders and patients, police, rearms units.
We hear the well-known mantra of penetrating trauma in our heads, “5 minutes and leave, 5 minutes and leave”, but a big part of us just wants to disregard that and for it all to be fine.
The patient ‘seems’ ok, the wound ‘looks’ ok, can I see the wound base?
Bearing in mind it has taken me 5 minutes to write this, is it really fair to expect ambulance staff to take control of this situation so quickly, bearing in mind the infrequency with which it is encountered (Henderson et al., 2019)?
In reality, what is the length of time we are spending on scene?
These are questions we wanted to answer when starting our study (Cowley et al., 2019). As a group of specialist paramedics, we felt ‘anecdotally’ that when we arrived at scene, there was a general apathy towards scene times.
So, we looked into it. We found that, in our trust, scene times in central stabbings were about 29 minutes with no specialist involvement, and dropped to 19 minutes with a specialist on scene — a reduction of 38%.
Moreover, the triage to a major trauma centre improved from 37% to 81%.
Now, the study isn’t perfect and we should be cautious in transferring the findings to other trusts with different staffing and trauma models, but it certainly gives food for thought.
Why did our data show such a strong tendency for non-specialists to remain longer on scene?
In central penetrating trauma, where the patient is not in cardiac arrest, there is little that can be done in the pre-hospital environment, other than expose the patient, cover wounds (either ‘bleeding’ or ‘sucking’) and get moving.
We must resist the temptation to take lots of observations, to do a 12 lead ECG or ensure all AMPLE information is noted.
It is impossible to gauge the depth and severity of any wound from its external appearance and, given the general demographic of patient and their ability to compensate, they really need to be with a surgeon at a major trauma centre, rather than on the street or the back of our ambulance.
So why aren’t we doing it and what can be done to improve outcomes and reduce deaths from knife crime?
We propose that approach should be three-fold, and none are easy. Firstly, we need to continue to educate ourselves.
At the moment it seems clear that the presence of a specialist improves the situation, so tasking models should ensure they continue to be dispatched wherever possible.
In addition, we need to continue to spread the message of minimal interventions and reduced scene times — empowering our staff to do what the patient needs, and take them where they need to go, rather than the ‘complete obs and paperwork’ approach that is used on most incidents.
We must continue to train harder or, perhaps, just more efficiently.
As technology improves it may become easier and easier to fully immerse our staff in training incidents — certainly the improved accessibility and sophistication of Virtual Reality systems may mean that the non- technical aspects of these incidents, which are normally so hard to recreate, become that bit more reproducible.
However, this can only be one part of it — there is simply not the exposure or training capacity for non-specialists in these highly dynamic situations to expect perfect performance every time. That is not fair.
So, perhaps a more ‘out of the box’ approach is needed?
Some interesting evidence emerged last year showing that victims of penetrating trauma that presented at hospital by alternative means (e.g. private vehicle, taxi, police car) had a significantly lower likelihood of death than those brought in by ambulance (Wandling et al., 2018).
Admittedly, it’s not directly transferrable due to the setting of the study, but there are not infrequent reports of patients deteriorating in taxis and police cars whilst waiting for an ambulance, when a hospital is close by.
It would need a step change in attitudes surrounding the 999 culture, but police medics are an increasing part of their service and so it is not beyond the realms of possibility to develop a system where they are the conveying resource when an ambulance is not on scene.
Finally, the most obvious one is to stop people stabbing each other in the first place.
The Serious Violence Strategy was announced almost two years ago by the Home Secretary and, whilst it will take time to assess its impact, the pessimists amongst us will feel it is unlikely to solve the problem.
The vast majority of knife injuries are due to crime, drugs, mental health or, most likely, a combination of all three.
To suggest these are easily addressed would be optimistic to the point of naive, but people are trying and perhaps one of the most interesting, and promising interventions right now is the work of organisations like Redthread (many others are available) who, amongst other work, target the victims of knife crime when at their most ‘vulnerable’, often when lying in the resuscitation room with an unclear prognosis.
Their current reach is across hospitals in three of our major cities but it would be good to think that, in time, this reach will grow and perhaps they could move their focus from the resus room to the ambulance?
In summary, penetrating trauma kills quickly and subtly and, like so much serious crime, affects many more people than just the ‘patient’. It will occur more and more in the foreseeable future.
If you haven’t encountered it yet, you will. If you do encounter it, you will see it more often.
We need to be ready; we need to empower ourselves to do the bare minimum and quickly move to an appropriate hospital.
Perhaps, most of all, we need to continue to develop the wider system to minimise the impact and, eventually, put the numbers back on a downward trend.
1) Allen G., Audickas, L., Loft, P., Bellis, A. (2019) Knife crime in England and Wales. House of Commons Library (SN4304).
2) Cowley, A., Durham, M., Aldred, D., Crabb, R., Crouch, P., Heywood, A., McBride, A., Williams, J., Lyon, R. (2019) Presence of a pre-hospital enhanced care team reduces on scene time and improves triage compliance for stab trauma, Scan J Trauma Res Emerg Med 27:86.
3) Henderson,T.,Endacott,R.,Marsden,J.,Black, S. (2019) Examing the type and frequency of incidents attended by UK paramedics, J Para Prac 11:9.
4) Wandling, M.W., Nathens, A.B., Shapiro, M.B., Haut, E.R. (2018) Association of Prehospital Mode of Transport With Mortality in Penetrating Trauma: A Trauma System-Level Assessment of Private Vehicle Transportation vs. Ground Emergency Medical Services, JAMA Sug, 153:2.