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Are road-crash victims dying unnecessarily because of our trauma care?

Joanna Harris. Photo/Adrian Malloch

As our road toll reaches a seven-year high, the NZ Transport Agency has called in a team of Australian experts to review post-trauma healthcare.

The police serious crash unit report charts Joanna Harris’s injuries in a list of bullet points: fractured ankle; fractured knee; broken femur; broken right arm; broken right elbow; fractured ribs; fractured neck; ruptured spleen; ruptured liver; damaged peritoneum.

And that was not the worst of it. Harris was 34 weeks pregnant. Her baby did not survive.

Harris has had to separate her grief over her baby’s loss from the gratitude she feels that she is alive, one year after a speeding driver lost control of his van while overtaking in the wet and ploughed head-on into her car on the notoriously unforgiving stretch of State Highway One at Dome Valley on November 25, 2016.

She was in and out of a coma for four weeks and in hospital for 13. She still spends much of her time in a wheelchair, but in the past five weeks, she has started to walk with the aid of a crutch. She can now manage 20m before fatigue and pain overwhelm her.

Her body is a patchwork of scars. A strip of colourfully tattooed skin from her back has been grafted on to her right elbow. It may look odd, but she’s thankful she has the arm at all.

If the catastrophic collision had occurred in any other region, Harris would probably have died: the Auckland Westpac Rescue Helicopter is the only one in the country to carry a trauma doctor on board. He administered a mid-air blood transfusion and it saved her life.

For Professor Ian Civil, co-director of Auckland City Hospital’s trauma service and leader of the Major Trauma National Clinical Network, Harris’s survival is an example of the improvement in the region’s standard of trauma care. She would have died if her crash had happened five years earlier, he says.

Every aspect of her care went to plan, but that doesn’t always happen in every part of the country. Now, the New Zealand Transport Agency (NZTA) has commissioned a review of the treatment that road-crash trauma patients receive, from the moment paramedics arrive through to rehabilitation after discharge from hospital.

In what is believed to be the first review of an entire country’s trauma services, a seven-person team of Australian trauma experts from the Royal Australasian College of Surgeons (RACS) have recently made a week-long visit to assess trauma services in all the main centres. The team, which includes a critical-care intensivist, two emergency physicians, two trauma experts and a surgeon, is investigating, among other things, the timeliness of transport to hospital and of surgical interventions.

Harris' wrecked Toyota.

By the book

Harris’s case is a textbook example of how things should work. It took rescuers 30 minutes to cut her from the wreck of her Toyota people-mover. By the time she was loaded into the rescue helicopter, her internal bleeding was so bad that she had no recordable blood pressure.

When she arrived at Auckland City Hospital’s emergency department at 5.50pm, doctors put her chance of survival at less than 50-50. The haemorrhaging was so severe that she triggered the emergency “Code Crimson” response the hospital had introduced barely a year before. When it is activated, key personnel from all the relevant specialties – surgery, the emergency department, anaesthetics, nursing, radiology and the blood bank – effectively “drop everything” and race to the resuscitation room.

“Having all the key people together speeds up the decision-making,” says Civil. “One of the critical parts of getting a good outcome is not having remote and delegated decisions, but having someone there who says, ‘I’m taking this patient to the operating room right now.’”

Harris was on the operating table 40 minutes after her arrival – an amazingly swift response, says Civil.

That night, surgeon Li Hsee led the operating team of 15 that included an obstetrician, theatre nurses, an anaesthetist and two surgical registrars. He told the Listener that stopping Harris’s internal haemorrhaging was the first priority. “This was emergency damage-control surgery. We have a patient who is bleeding, in shock and physiologically unstable.”

Ian Civil, co-director of Auckland City Hospital’s trauma service. Photo/Ken Downie

Such operations are not uncommon for the team, but Harris’s pregnancy added to the technical complexity and upped the emotional ante, too. Her spleen was removed and her liver stitched and packed before her baby was delivered by Caesarean section. Hsee knew from an earlier ultrasound that there was no fetal heartbeat, but the loss of the baby was tough on everyone in theatre.

Since it was introduced, in August 2015, Code Crimson has been called 40 times, and in two-thirds of those cases, the patients survived. Half went directly to the operating theatre. Civil says it’s difficult to know how much the code helped because different patient groups are hard to compare but “we think this is the right thing to do”.

Harris also benefited from changes in the hospital’s blood and fluid resuscitation strategies. Before about 2005, most haemorrhaging patients with low blood pressure were given saline to pump up the pressure in their arteries and veins. “It was just a hydraulic business,” says Civil. “If you’ve got a hose and there’s a leak, if you put a lot of fluid in, the pressure going out the end will be the same, but a lot will leak out the cut in the side.”

At that time, doctors did not realise that volume resuscitation was making patients bleed more. Now, they are given only enough fluid to keep them alive, and doctors don’t try to bring their blood pressure back to normal until they’ve stemmed the bleeding.

The type of fluids given has also changed, from saline to agents that promote blood clotting. Many patients with the kind of severe bleeding Harris was having also become “coagulopathic”: their blood doesn’t clot, so pumping them full of saline actually makes things worse.

Harris and her sons. Photo/Adrian Malloch

Consistency of care

A major centre such as Auckland would be expected to have the staff and resources to create a centre of excellence, but Civil wants greater consistency of care around the country, so outcomes like Harris’s happen more often. “There’s quite a lot of variation, and that’s bad for quality.”

Sydney surgeon John Crozier, who chairs the RACS’s national trauma committee, says he’s sure the review will identify ways that the trauma service could work better. “But the spirit of the process is not about aggressive fault-finding. It’s for the betterment of people who are injured, to make sure they don’t fall through the cracks, and to make sure deaths that can be prevented are being prevented and the outcome for survivors is as good as it can be.”

Trauma patients will be asked about their experiences, and trauma staff interviewed to enable reviewers to get a sense of their morale, and the level at which their teams are functioning, both internally and in collaboration with the rest of the hospital.

Civil hopes the review will help to bring the country in line with international best practice. “I think New Zealanders have been denied exemplary trauma care over many years because health politicians at every level have taken the view that trauma is unpredictable: you can’t plan for it and it doesn’t happen to the people you and I know and it’s not like cancer or heart disease that happens to deserving members of the community through no fault of their own.”

He says that sends a subtle message that we should simply tolerate ad hoc trauma services. “The word accident is in itself a bad term, because it puts us in a mindset that we don’t know what’s going to happen, we don’t know how many of these there will be, we can’t plan for it and therefore we can’t expect any particular outcome.”

More than half of major trauma is the result of road crashes, twice as many as falls (26%). Almost 1700 major trauma victims a year are admitted to hospital, and 10% of those die. That’s a big improvement on Auckland’s 16% average mortality rate in the 1990s, but in the Australian state of Victoria, which is seen as an international leader, the rate is just under 6%. Civil says if we could get to Victoria’s level, about 60 patients a year who are now dying would survive.

“We are not doing as well as we could because we haven’t applied ourselves to it,” he says. “We are getting there, but the health bureaucracies at the Ministry of Health and the ACC are difficult to deal with in terms of commitment to this process, and I worry it won’t be sustained.”

Harris would spend 13 weeks in hospital.

Road-safety pillar

Civil asked the NZTA a year ago why post-crash care wasn’t included in any of its strategy documents as one of the five “pillars” in road safety (alongside safe roads, safe speeds, safe vehicles and safe road use). His approach triggered the review now under way.

This year’s road toll – 337 when the Listener went to press – is the highest since 2010, so it’s a timely investigation. Associate Minister of Transport Julie Anne Genter is calling together police, the NZTA and the Ministry of Transport for crisis talks to develop an improved long-term plan for road safety. The National Road Safety Committee’s Safer Journeys action plan for 2016-20 does not mention post-crash care.

The NZTA’s director of safety and environment, Harry Wilson, told the Listener that the RACS review would help determine the correlation between trauma response and rates of serious injury and preventable death, to establish whether it should be included as a road safety pillar as it is elsewhere.

For trauma specialists such as Civil, it’s a no-brainer. “If you’re trying to improve road-crash outcomes, you should have a strategy for post-crash care.”

Nationally, the Northern and Midland regions are the only areas with dedicated trauma services. Civil says the high rate of road crashes in the South Island has prompted the Canterbury District Health Board to recognise trauma care as a major issue and it is now recruiting more clinical staff. The rest of the South Island and the lower North Island are still without a service, although they are collecting trauma-outcome data, which makes them more likely to notice if things are not as good as they should be. “So improvements happen whether you dictate they should or not.”

Civil says hospitals often don’t do teamwork and communication well, and this can also impair or delay a good outcome.

“It’s about making sure that anyone who has the potential to be a survivor is a survivor.”

Harry Wilson. Photo/NZTA

One small step

It was a fall, not a road crash, that prompted an overhaul of trauma care in the Waikato.

When canoeist Sam Laffey, 21, left his tent at a campsite north of Taupo around 1am on March 16, 2003, to have a pee in the bush, he stepped over a cliff, falling 20m on to the bank of the Waikato River below.

Flown by rescue helicopter to Waikato Hospital, the Auckland University student was admitted to the intensive care unit (ICU)    with a ruptured aorta, fractured pelvis, fractured skull and five brain bleeds. They were critical but survivable injuries. For 11 days after his admission, it looked as if Laffey would indeed pull through – by March 27, he was sufficiently improved to be transferred to the hospital’s high-dependency unit.

It was here the following day that things began to go badly wrong. Blood was leaking undetected into the cavity around his heart. His breathing became laboured, his heart rate and blood pressure spiked, and a yellow discharge from the site of his tracheotomy indicated he was also battling an infection.

Yet despite the mounting concerns of his parents and nursing staff, he was not returned to the ICU until the afternoon of March 31. The following day, rushed to theatre for emergency heart surgery, he suffered three cardiac arrests, which deprived his brain of oxygen for 10 minutes, leaving him effectively brain-dead. He died six weeks later.

The Health and Disability Commissioner’s finding that there was “no delay” in the transfer back to ICU was disputed in a report for the coroner by Auckland intensive care specialist Dr James Judson, who found Laffey’s medical supervision and care in the high-dependency unit (HDU) were poor. “Sam’s deterioration over the weekend while in the HDU was recognised by the nursing staff but not by the medical staff. His readmission to the ICU was delayed.”

In a complaint to the Waikato District Health Board, Laffey’s mother, Jenny, a nurse, said she sat with her son for four hours before his transfer to ICU “while his body popped and dripped with perspiration, his tachycardia and rapid respiration continued. I had asked all day about IV fluids. The ICU registrar came and told the nurse to get an assisted respiratory device. He tried to put an arterial line in. He tried twice and said he would come back in 10 minutes. He never came back.”

She says she became “absolutely desperate” that her son would go into cardiac arrest and herself sought out an ICU doctor. “All I wanted was someone to look at the whole person. I didn’t want a team of doctors looking at their part.”

Laffey. Photo/Laffey family collection

Waikato Hospital trauma surgeon Grant Christey, the head of the Midland Trauma System, never met Laffey, but says his case was a turning point for the hospital – and the region’s – trauma services. “It’s a little disappointing to me that it took a sentinel case like Sam’s to kick this process off,” he told the inquest in January 2008.

When Sam Laffey was admitted, the traditional model in trauma care was silo-driven. “It was decided somehow what the worst injury was, and the consultant looking after the worst injury kind of inherited the patient. That part was done really well – but what about the other injuries that require input from other specialties? If the services aren’t used to communicating and helping each other’s patients routinely, those needs aren’t looked after.”

Today, if a patient has two or more serious injuries, as Laffey did, they’re handled by the trauma service, with Christey as lead consultant.

“We know now that patients need more overview care to protect their physiology, not just their anatomy. They need risk mitigation. For example, if someone comes in with a bad chest injury, they’re prone to have respiratory failure, but they’re also prone to chest infections that keep them in bed longer and predispose them to other sorts of problems such as clots in the leg, losing body mass and loads of other things.”

The trauma service takes a “holistic view”, to ensure care is co-ordinated, risks are identified in advance and medical, surgical and nursing staff consult daily about each patient.

When Christey, who grew up in Hamilton, joined the Waikato DHB in 2006, the failings of the Laffey case were still front of mind with senior management, so when he suggested a trauma service be established, “the timing was right”.

“They knew the numbers were high and mortality was high,” he says. “They knew they had a problem.”

In the mid-1990s, the Waikato DHB’s mortality rate from major trauma was 25%; that figure had improved to 17% by the time Christey started, and was at 14% by the time the Midland trauma service was launched in 2010. The DHB’s fatality rate for severely injured patients this year is down to an astonishing 4.52%.

Laffey’s family had no idea his death had played such a key role in the transformation of Waikato’s trauma care. His father, Tom, says the hospital “closed ranks” when the family tried to raise their concerns and he was surprised to discover, through the Listener, that such significant changes had followed.

“At the time, I didn’t think I’d won. I thought it was a draw. But I’ve made a difference, haven’t I?” Asked if he would encourage other families to fight as they did, he replied, “It is too hard. But I would still do too hard again.”

The pain of Sam’s loss hasn’t lessened over time. Tom Laffey has crucified himself with guilt that he encouraged Sam to join the canoeing club and go on the trip that would ultimately lead to his death. Tom and Jenny’s marriage didn’t survive either.

The changes Sam’s death prompted do not comfort him. “Does it help? No it doesn’t. You’ve lost a son. There’s no help for that.”

In and out of a coma for four weeks, Harris was unaware of the time that the lifeless Bo spent lying beside her.

A life changed

In the lounge of her Wellsford home, Joanna Harris sits in her wheelchair and weeps at the loss of her son, too. “That’s him over there,” she says, pointing at the box holding his ashes.

Bo was due on January 11. She never met him, although she has photos of herself lying unconscious in the ICU, with Bo in the bed alongside. “I never got to hold him or touch him … or say, ‘Mummy loves you’ or ‘Goodbye’.”

The driver who changed her life – and ended Bo’s – lost his licence for seven months and was ordered to pay $9000 in reparation, including $5000 towards a car. Harris, 41, volunteers a day a week in a hospice shop, but will never return to her old jobs, cleaning, lawnmowing and landscaping.

The mother of four says the crash has been as hard on her sons – aged from 3 to 18 – and partner Kurt as it’s been on her, so she’s thankful she came back to them, through the efforts of the more than two dozen people involved in her care.

Lifting her glasses, she wipes away her tears with the heel of her hand. “I’m sorry. I can’t put it into words. The work they do just blows me away.”

Major trauma – by the numbers

  • The national incidence is 35.5 cases per 100,000 people, but there are regional variations, from 28 per 100,000 in the Northern region to 52 per 100,000 in the South Island.
  • In the year to June 2017, there were 162 in-hospital deaths from major trauma – about 10% of all major-trauma admissions.
  • There are marked regional differences in cause of injury. The Northern region has high rates of pedestrian injuries (at 8%, double that of the other regions) and assault, Midland has high rates of road crashes and Central and South Island have high rates of falls (29% and 31%, compared with 20% in Midland).
  • About a quarter of patients have to be transferred from the hospital they are initially taken to.
  • In the Northern and Midland regions, more than 40% of patients get to hospital within the so-called “golden hour” after an event, but in the Central region and South Island, the figure is less than 30%.

This article was first published in the December 9, 2017 issue of the New Zealand Listener.