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

Doctor

@ Risk

Training

Rqd

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Time

is

BLOOD

&

Life

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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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DCS – Liver Packing

Restore physiology before total anatomical correction

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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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ATLS – 5 Phases

Stop BLEEDing to save Life

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Polytrauma Mx Concept

Time – Blood & Life

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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

Birth = Start of Countdown to Death

Healthy Sick Aging

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17 % 29% 33%

TMH AED Injury % Trend

2006 - 2016

20 > 18 > … 14 % - Total Attd

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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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Types of Learning – K-S-A-Beh

Patient Safety & Staff Benefit

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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Traumatology EBM

BEST does not exist !

Always look for BETTER !

沒有最好

只有更好

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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Symposium / Lecture

100 to 300 Staff together

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

Boston Marathon Bomb 15 Apr 2013

Life-saving HATourniquet

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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

CCTP – Trauma Simulation Training

• Overall Satisfaction:

– 8.97

• Competence:

– 6.58 -> 8.24

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Pelvic # - Hematoma

ruptured & rebleed

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Sam Sling

Vs T-POD

1) EPF 2) PPPP

3) Laparotomy

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Blue

rectangle -

extent of

the T-POD

Polytrauma Mx Concept

Time – Blood & Life

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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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Cl Sim – Fun & Sorrow Virtual Reality - Pokémon

台 上＜造假＞一分鐘

台下十年功

Video – Plane Crash

Disaster Polytrauma

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Resus Rm Backdrop

Adrenalin Surge

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Trolley Transfer from

Ambulance – to a District ED

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Trolley Transfer to

Ambulance – 2nd

Tr Diversion

Weary HCA

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Done + JOY !!

造假不離

三兄弟

TMH – Skills Centre

K L Cheng Henry Wong

C W Kam

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Motivation – Learning & Work

>> Pleasant / Safe /

Controlled Environ / Rewarding

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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

Fun of Trauma USG

Descendants of the SUN

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Korean

* Oppa

* Agazi

* Ajuma

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宋仲基 🙍 宋慧喬 👩

太陽的後裔 War-place Doc / Savior

Korean

* Oppa

* Agazi

* Ajuma

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宋仲基 🙍 宋慧喬 👩

太陽的後裔 War-place Doc / Savior

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Trauma Training

Revision PPP – well in advance

在家靠父母

出外靠朋友

(做工靠同事)

< 讀書靠平時 >

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

Private Tutors

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Traumatology

Clinical Mentor

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Play Safe + Rapid Response

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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Trauma Training + Services from World, HK to HA

Mission CW Kam Mar 2016

培訓專業 完善系統

護愛病人 拯救生命

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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

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