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 ©Copyright
 Published: 28/11/2011

Trauma in Provincial New Zealand


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Outline

Trauma in Provincial New Zealand
Mark Sanders
General Surgeon
Whangarei Hospital

Trauma in the Provinces
• What constitutes the ‘provinces’ or ‘rural NZ
• Features of the population
• Trauma mechanisms
• Workload
• Issues in rural trauma

Provincial New Zealand?
Provinces
“portion of an empire or state marked off for purposes of government or in some way historically distinct”

NZ population
• 53% New Zealand population ‘provincial’ or ‘rural’ districts
– (23% ‘provincial’, 30% ‘rural’)
• ‘provincial/rural’ different things in different countries
• Different degrees of ‘rural’

Rural Population
Is it different from its urban counterpart?
• Health?
• Employment?
• Education?
• Age demographics?
• Expectations?
• Wealth - individual?
- region?
• Culture?

Northland
• 146,000 3.7% NZ population
• 71,000 in Whangarei
• 25% under 15 years (22% NZ)
• 13% over 65 years (12% NZ)
• 27% post school qualification (32% NZ)
• Higher unemployment: 10.2% (7.5% NZ)
• Workforce: forestry & agriculture
• Higher single parent families
• Lower average income
• 25% Maori population
– Increased co-morbid factors
– Maori medicine
– Whanau support

Seasonal fluctuations
• Increased tourists - local
- overseas
• Increased demands (trauma) at certain times of the year
• High risk recreational activities - remoteness

Non-demographic factors
• Roads: Northland 6500kms - 41% sealed (70% NZ)
- Winding
• Speed: mean open road speed - 96.3kph
(lowest in provincial NZ)
• Seatbelt usage:90% (lowest in NZ)
94% in urban areas (99% AKL)
• Alcohol: 19% of all MVA (14% NZ)
34% of serious/fatal
Major road safety issues in Northland
• Crashes on bends
• Alcohol & speed
• Roadside hazards

More exaggerated the more ‘rural’ get
• Far North - Higher speeding and alcohol use
- Higher death and serious injury
• Isolation - time to detection
- transport issues
• Most MVA happen on major highways

• Acident distribution on roads

Impact on HealthCare
• Type, numbers and timing of trauma
• Number with associated co-morbidities
• Poorer social situations, increased demands on services
• Resource implications
MVA alone: $94 million in Northland
• ? Provinces less able to afford such costs

What about numbers?
All Injuries
• Fatalities

Mechanism of Trauma
Falls
• Proportionally less in provinces
• ? why
Burns
• Also less in provinces

Mechanism of Trauma
Motor Vehicle Accidents
• Higher proportion and largest overall sub-group especially in the provinces
Northland: 35 deaths 2003
Provincial death rates higher than metro
BOP > Cant > Southland
1:15 serious MVA resulted in death (1:50 Auckland city)

MVA - Fatalities
MVA - Serious

“Rural residents are 50% more likely to die from trauma than their urban peers”
Rural Trauma: The challenge for the next decade” Rogers et al. J of Trauma. 1999; 47(4): 802-821
However:
“hospital volume (& by extension rurality) did not affect survival after injury”
i.e. rural care no worse than/as good as urban
Death rate 1^ attributable to gaining fast access to hospital care.

What actually turns up?
• ED: 21437 2003/2004
• Trauma related 5815
• Admitted 1547 (40% #s alone)
• 31 transferred straight to 3^ centre

Whangarei Base Hospital
• 225 beds
• 5 General Surgeons
(4 FTEs)
• 5 Orthopaedic
Kaitaia Hospital
Rawene, BOI & Dargaville

WBH - services
General Surgery
• No vascular on site
• No neurosurgery
• Limited Paediatric
• Limited Plastic
• Everything else!
• 2 trainees
Orthopaedic
• Complex pelvic #s transferred
Radiology
• CT & MRI
• Very limited intervention
ICU
• 3/4 ventilated or 5/6 HDU
• ‘Intensivists”
ED
• 2 consultants
• 3 ‘seniors’ / MOSS
• 0/1 trainees
Proximity to Auckland
• 180 km
• 2 hours driving
• 35 mins flight time

What are the issues?
“Thoughts”
• Some proven
• Some hypothetical
• Some ? irrelevant
• Some controversial

Based on Northland but nationwide ‘provincial’ issues
Pre-hospital issues
• Remoteness of some accidents
- poor cellphone coverage
- tend to be forestry / agricultural / MVA
- hypothermia becomes an issue
• Time taken to recover patient
• Transport issues

Pre-hospital cont’d
• “Scoop & Run” less of an option
• ? more at the scene
• ? more Paramedics on rural ambulances
• Helicopter recovery
– 313 flights per year
– recovery & transfers
– ~ 150 trauma

Hospital issues
• Trauma team - ED, ICU Gen surg
- personnel availability
• Lack of a 24 hour ED senior
Imaging
• No angiography & therapeutics
- ? unnecessary operations
• CT scan availability
• Teleradiology - reliable link. Definite role

Telemedicine
• Significant role for provinces
• Rationalise and prioritise transfers
• Reduces discrepancies & ? improve outcome
• Digital pictures - from scene, between hospitals
• Clinical meetings - keep current
Telemed J E Health. 2003;9(1):3-11 & 2000;6(3):297-302

Transfer of patients
• Tyranny of distance
“just close enough” vs. “a little too far”
• How & when
• Bed availability

Surgical issues
• Lack of all sub-branches makes for the “occasional specialist”
• Overall lower numbers reduces experience but ? made up for by increased on-call
• Lack of one ‘trauma service’ where expertise can be concentrated
• Is being a true General Surgeon an advantage?
• See trauma as a subspecialty in itself. Have one surgeon in the unit with an interest?
• Maintenance of skills / updates
- “Injury” conferences. DSTC courses
• Relationship with 30 centres
• More junior Registrars, ? less able to cope with major trauma
• Audit - money for dedicated database

Other Specialties
• ICU / anaesthetics
• Ward staff - trauma often scattered through the wards - dedicated ward
• Theatre staff - lack of experience with infrequently used equipment - regular updates/DSTC

Does trauma pattern matter?
• Vehicle safety issues may reduce experience
• With the higher frequency of certain types of trauma in the provinces vs. urban areas, is it a different disease?
• If so would that impact on training?

Training for ‘rural’ trauma
• Australasian system very good
• Generalist overall approach
- confident & competent for non body region specific trauma
• Trauma receives a status = other sub-specialties

Summary
• Looked at some of the population and geographical issues
• Idea of the make up of provincial trauma
• Hopefully raised some interesting thoughts about the medical issues involved


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