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Traumatology

INTERVENTION TIME OF TRAUMA UNIT

The National Orthopaedic Hospital, Enugu presently serves as the major trauma centre for the southeastern part of Nigeria. Up to 65% of admissions into the hospital come through the trauma unit therefore priority development should be given the unit.


Primary responder1 (trauma doctor)
The trauma doctor must be available at the unit on a 24 hour basis and must see patients immediately on arrival. The emergent nature of the patient should be determined and vital signs recorded. The primary survey of ATLS should be done immediately. Any instability must be immediately addressed. Where instability exists, as resuscitation is taking place the senior resident and consultant must be immediately contacted. The senior resident is expected to join in the resuscitative efforts. Where instability is absent following primary survey the trauma doctor must immediately inform the senior resident of the patient. Within 15 minutes of the information the senior resident must review even when adjuncts to primary survey are unavailable. This review will help guide ancillary investigations and missed diagnoses by the trauma doctor. The senior resident must review again with results of investigations.


Primary responder2 (senior resident)
The designated senior resident whose name appears on the roster must remain in the hospital throughout the duration of the call period. It is his/her responsibility to get periodic updates from the trauma unit, and to inform his supervising consultant of any patient before embarking on any interventions (excluding adjuncts to primary survey). This officer is expected to participate in emergency resuscitation of patients and review all patients admitted into the unit for the unit on call even when investigation results are yet to arrive. This should be within 15 minutes of patient’s arrival.
Where specific requests for a unit other than the unit on call exists the senior resident on call must first review before transferring responsibility to the requested unit’s senior resident. Since all doctors are on call every day for their unit inpatients the requested unit’s team members should then take over. Care of the patient must not diminish in the handover period. The receiving senior resident remains responsible until the physical presence of the requested team’s senior resident arrives.


Primary responder3 (consultant)
The consultant on call has vicarious responsibility for all activities carried out under his/her unit and therefore must be informed immediately of unstable patients arriving during his/her take, and of every patient admitted under him/her before any intervention by the senior resident including those discharged or transferred without intervention. 
The consultant is expected to give directions for patient care and be available to review the patient in a timely manner; and conduct a trauma round the following morning by 8.15 am with all members of the team on call. All members include the night nurses in trauma, the anaesthetic, laboratory and pharmacy staff that did the call.
Where doubts exist about the suitability of a patient for orthopaedic or plastic intervention the consultant in trauma shall resolve the direction of the patient. All staff/staff children presenting to the emergency shall be seen as above with the consultant staff clinic replacing the consultant orthopaedic/plastic surgeon.


Mass casualty
Ina situation where more than five unstable multiply injured patients arrive simultaneously all doctors on call (plastic and orthopaedic; senior and junior residents) must be immediately called upon. The most senior of them should serve as the triage officer until further directives are received by the most senior consultant on call (or first responding consultant).
The trauma doctor will be held liable for morbidity and mortality if he/she fails to activate the emergency response plan of involving these extra doctors in the face of a mass casualty.


Multiple casualty events
Where patients requiring resuscitation trickle into the emergency department once the number requiring monitoring exceed five the trauma doctor must request help from the unit doctors on call and the doctor on ward call. Each unit has the responsibility of ensuring proper monitoring of every received patient. Transfers of patients should be considered in conjunction with the consultant on call (who may be the staff doctor; or trauma consultant where the patient is not clearly plastic or orthopaedic).


Logistics
Part of what causes delays in intervention includes the time it takes to bring the 2nd on call. The trauma intercom should be immediately repaired. The call rooms designated for senior residents must be immediately appropriated.
It is advised all residents in the teams on call be available at the hospital during their call periods. Ideally a block of two bedroom flats should be built for a limited number of residents, at least 12. Proper residency demands that the doctors live within the premises. This can be done over the next five years. Alternatively the building being erected by the Enugu state governor may be converted for this purpose.