Physiotherapy Trauma Talks
In Physiotherapy Trauma Talks we discuss the key roles that physiotherapists and other healthcare practitioners play in the management and rehabilitation of patients with traumatic injury. Experts in trauma care offer their insights about in-hospital patient care and post-discharge follow up service delivery. New research in the field of trauma care and rehabilitation is shared to provide answers to your questions.
Physiotherapy Trauma Talks
Navigating the Complexities of Trauma Care in South Africa with Professor Timothy Hardcastle
Professor Timothy Hardcastle, a pioneering trauma surgeon and Head of the Trauma and Burns Clinical Department at Nkosi Albert Luthuli Hospital in Durban, shares his incredible story from a young first aider to a leading force in trauma care. With his extensive experience both locally and internationally, he sheds light on South Africa's unique trauma landscape, where healthcare professionals face an array of challenges, from gun violence to road traffic accidents. Discover the intricate realities of treating young adults with violence-related injuries and gain a deeper understanding of the complexities inherent in South African trauma care. Professor Hardcastle's insights exemplify the power of teamwork and the dedication necessary to navigate the demanding field of trauma care effectively.
Podcast website: https://physiotherapytraumatalks.buzzsprout.com
‘Cardiopulmonary Physiotherapy in Trauma: An Evidence-based Approach’ published by World Scientific: https://doi.org/10.1142/13509
Hi there, fellow physiotherapists. I am Helene van Asvegen, your host for Physiotherapy Trauma Talks, where we discuss everything related to trauma care. So if you are passionate to learn more about physiotherapy in the field of trauma to ensure that you provide the best possible care for your patients, then this is the right podcast series for you. With me today is Professor Timothy Hartcastle, who is Head of Trauma and Burns Clinical Department at Nkosi Albert Lutuli Hospital in Durban. Tim is also an Honorary Associate Professor in Research at the Faculty of Health Sciences at Durban University of Technology and Honorary Associate Professor of Trauma and Surgery at the University of KwaZulu-Natal in Durban, south Africa.
Speaker 1:Tim, thank you for joining me today. It's an honor to have you as a guest for this episode. I know that you've published extensively in trauma care related to trauma in South Africa, but also on a global level, which certainly makes you an expert in the field. So it's lovely to have you with us as we explore the role of the trauma surgeon in managing patients with multiple injuries. Welcome, thank you. Okay, as we start off, can you tell our listeners a little bit about yourself and how you found yourself working in Trauma Key?
Speaker 2:Okay, well, I grew up in Belleville in Cape Town and in my high school days got involved with the South African Red Cross Society as a school first aider and as I got slightly older was able to work on the ambulances. And then, when I started university, hoped to get into medicine. Ended up doing a first year of BSC and then followed by the scores that were high enough and I got into medicine, ended up doing a first year of BSC and then followed by the scores that were high enough and I got into medicine at Stellenbosch, did my medical training there and from my second year already I would be found on weekends helping out in the trauma units, suturing patients, helping put catheters in, all that kind of things. To get experience. And you know, once I qualified came up to KwaZulu-Natal to do my internship at Edendale, where it was in the middle of the it was 1995. It was just post-apartheid and there was still quite a lot of violence. We saw lots of trauma at Edendale. And then went back to Cape Town, worked as a medical officer for a year in the trauma unit, along with the PEDSURGE unit, and then got my registrar post in surgery, did my surgical training there and I think a total of about 15 months if you include the ICU time was trauma.
Speaker 2:When I qualified in 2002, I was asked to run the trauma unit at Tigerberg for the for the next five years. I was initially in a junior specialist and then a senior specialist position attached to the University of Stellenbosch, and then in 2008 beginning of 2008, I was recruited by David Mucketts to move up to Durban as his number two for the newly opened Incorsi Albert Latuli Central Hospital, where they wanted to set up the trauma fellowship training program. But there was nobody registered in trauma surgery, which, in 2007, I'd been registered in trauma surgery, was one of the first 15 people that were so-called grandfathered into the specialty. And yeah, the rest is history. As they say, then it's okay to go slowly, slowly working on a PhD, working on promotions, working on eventually taking over the running of the unit from David Muckett. So the passion was there from a young age. Initially I wouldn't have thought of going into surgery, but emergency medicine didn't exist at the time and surgery was then the route to trauma care.
Speaker 2:So that's how I ended up doing trauma.
Speaker 1:Yeah, fantastic. And based on your experience over the years, how would you describe the trauma context in South Africa? What type of injuries do you often see in your emergency department and the causes of those injuries?
Speaker 2:Look, it's a wide spectrum.
Speaker 2:If I think back to my time at Tigerberg, which is a more general emergency department, we would see everything from minor wounds that were true accidents Someone cuts themselves in the kitchen and they have a tendon injury or what have you right the way through to polytrauma patients, from multiple gunshots, multiple stab wounds, severe car crashes, falling from height, industrial incidents.
Speaker 2:Where I work now, we primarily set up for the ICU care of the complex trauma patients.
Speaker 2:So we see a lot more blunt trauma than penetrating, but it's still around about a 60-40 mix, whereas but it's still around about a 60-40 mix whereas in the more general emergency departments as much as 60% can be penetrating and 40% blunt, we're kind of the opposite because we set up for the complex patient that needs neurosurgery and plastics and vascular intervention, compared to the sort of general surgical units that can manage the straightforward stab abdomens and gunshot abdomens. If you look at the spectrum probably of our penetrating trauma still in this country, about 60 to 65% will be stab wounds and about 35% to 40% will be gunshots, and then in the blunt trauma it's probably about a 50-50 mix between blunt assaults beaten over the head, beaten with shumbucks these guys that have then got crash syndromes and then motor vehicle crashes, and again in South Africa. Our motor vehicle crashes have a very strong slant towards pedestrian injuries and that's because people just don't obey the road laws or Europe, where the car crashes will be 90% car or occupant and about 10% pedestrian, whereas here it's 30% to 50% pedestrian.
Speaker 1:Yeah, so definitely a bit of a different trauma landscape, absolutely, and the average age of patients that present to your emergency department? Would they be young adults or the elderly, or is it a mixture?
Speaker 2:It varies by mechanism of injury. The knife and gun club, as we like to call them, usually made up of skabengas or people who are walking home from church and just happen to get shot. They are generally in the younger category, sort of 18, 16, 18 years of age up to about 35. The groups that have the pediatric group. We see mainly pedestrian collisions and then kids that fall and hit their heads on something. They fall off a jungle gym or what have you, and then a lot of pediatric cases will be burns, quite severe burns. In the older category is often your pedestrians as well, but also drivers, occupants and sometimes the industrial crashes and the industrial incidents will be in the older age group as well. Unfortunately, what we do see in the older age groups a lot of particularly older females who've been robbed and beaten up at home and and they since elder abuses is becoming a big problem just much, just as much as child abuse and pregnant woman abuse is a problem.
Speaker 1:Okay, yeah. So when a person with these types of injuries present themselves at the emergency department, what principles guide your management of these patients? So, internationally.
Speaker 2:The sort of standardized approach, and with certain exceptions, is what's known as the ATLS approach or the Advanced Trauma Life Support approach, which is based on a course that's taught through the American College of Surgeons, currently in about 88, 89 countries worldwide, so about half the world, about half the world and that's based on an approach to saving the trauma patient's life by dealing with what kills them the quickest first, and so, depending on whether there's active bleeding, if there's active external bleeding, you control that first.
Speaker 2:Otherwise, you, in the order of preference, go secure the airway, protect the cervical spine, assess breathing, intervene if necessary, assess circulation, start treating bleeding and shock, look for where the patient is bleeding, assess level of consciousness and, if necessary, you might have to secure the airway based on level of consciousness and, if necessary, you might have to secure the airway based on level of consciousness and then keeping the trauma patient warm but at the same time undressing them completely so that you can examine the whole body, because you don't want to miss, miss little holes and miss things on the back or, yes, definitely occult injury yeah so that that's the sort of first phase we we call it the primary survey okay, and then what would follow?
Speaker 2:once that is done, we move on to what we call adjunct. So that's where we do some basic x-rays chest x-ray, pelvis x-ray for blunt trauma, use of ultrasound to make sure that there's no intra-abdominal or intra-thoracic problems and then we move on to what's known as the secondary survey. While we send off bloods to the lab and the secondary survey, you literally start from the longest hair to the longest toenail and you examine the whole body from top to toe.
Speaker 1:Okay, so it's a very detailed investigation.
Speaker 2:Yes, yes, and you know if you cut steps, that's when things get missed and it's a team effort. You know it's not just in the real world situation. When we train ATLS we train as one doctor, one nurse, one patient. But in the real situation you're dealing with a team. So if you're lucky, even in a small hospital, you'll probably have at least two doctors around. You'll have two or three nurses, you might have the cleaner and the porter who's going to help you with your log roll. In a small hospital, in a big environment, in my hospital, for example, there will always be a consultant in charge of the recess. There will be between two and three doctors and two and three nurses. There'll be a radiographer with a mobile x-ray machine. There'll often be our critical care technologist who brings our video laryngoscopy device and is available if we have to rush the patient into theatre to run the cell saver for us so that we can harvest and clean cavity blood and give patients their own blood back again.
Speaker 1:Okay, that's very interesting. So it's a real team effort, absolutely yeah, and to the patient's benefit, I'm sure. How long would the primary and secondary survey take of a particular patient?
Speaker 2:You know it's a variable time. The primary survey probably shouldn't take you much more than about 15 to 20 minutes, depending on how much you have to intervene. So if the patient's got a major airway issue and you need to set up your team and do an intubation and pre-oxygenate and prepare everything properly and do a smooth intubation and get someone to hold the C-spine while you do it, because you don't want to intubate patients with collars on and things like that then the primary survey may be prolonged. But ideally you want to go through the basics of the primary survey in around 20 minutes, get your adjuncts done over the next 10 or 15 minutes and then by the end of the first hour you should have at least three more advanced imaging have completed your secondary survey.
Speaker 1:There are always exceptions.
Speaker 2:Some patient will come in and his airway and breathing is okay and he's got a belly full of blood and no blood pressure and the only way you're going to deal with that is stopping the primary survey right there and moving him to the operating room and stopping the bleeding surgically. So your primary survey might take five minutes, but it then has to be continued once the patient is completely resuscitated and the bleeding is stopped and you've got them in the ICU.
Speaker 1:Yeah, and then I suppose management of pain would be at the forefront of your mind after you've stopped all the catastrophic bleeding and done your primary survey. Is there any particular types of drugs that you administer for pain management at that stage?
Speaker 2:We're very fond of what we call multimodal analgesia. So in the acute 72 hours we don't like using non-steroidals because they hit the kidneys they worsen the blood clotting.
Speaker 2:So the drugs of choice that we use is a mixture of an opioid and there's quite a few on the market. So from the cheap stuff like morphine all the way up to the really expensive stuff like fentanyl or sufentanil. So we'll usually combine an opioid with and we like the use of ketamine because it's both analgesic and sedative. So particularly in the head injuries we've moved away from propofol and we're using quite liberally ketamine. It's also good if you have to intubate them in the recess area on ketamine you can keep the ketamine going and the anesthetist will take over the anesthetic and and do a intravenous anesthetic with the ketamine and you can continue it. In the icu for analgesia we will, with the one inverted commas, non-steroidal that is safe in the early phase is paracetamol and you know if the patient is is in extremis, we can use that as an intravenous paracetamol and you know one gram of of that is equivalent to 10 milligrams of morphine. So it's a morphine sparing and we'll often use the three or four in combination and then we may or may not add a sedative drug.
Speaker 2:So the problem with certain of the drugs like propofol and the benzodiazepines which people are inclined to. You know the old morphine morphine midazolam strong arm intubation is hopefully dead and buried. But midazolam, for example, gives you some sedation. It also drops your blood pressure and unfortunately gives no analgesia. So we like to use a combined thing and then once the patient starts recovering in the ICU by about day three or four unless they've got further major surgery planned that's when we'll bring in things like nonsteroidals, lignocaine infusions, especially if they've had abdominal surgery. We like to use lignocaine infusions because it doesn't cause an ileus. Particularly the combination of lignocaine infusions and ketamine works very nicely.
Speaker 1:Okay, that's really interesting and in general ICU settings there's this concept of trying to awaken the patient much earlier during the ICU care than what would have been done 10 or 20 years ago. Is that also a principle of management in a typical trauma ICU setting?
Speaker 2:Again, it depends on the patient and it depends on what's being done for them. So if they've got a traumatic brain injury and again this is not a universal thing, but in our unit they get full sedation and ventilation for a minimum of 48 hours, which we call mirror protection, and then we will reassess and wake them up. If they haven't got a traumatic brain injury and they're not a damage control laparotomy, that's got a temporary closure and we know has to go back to theater in 24 or 48 hours, yes, then we will certainly try and we certainly maybe not so much sedation and analgesia hold, but we'll certainly try and get the patient off the mechanical ventilator mode onto a spontaneous mode of assisted ventilation, such as pressure support, cpap, very early on, by about 24 hours we'll start weaning and try and get them onto things.
Speaker 2:We often don't get to the point of early extubation and we may, depending on the injuries, determine that the patient, by day five, needs an early tracheostomy. But we certainly aim to get the oral tubes out in the sort of five to seven days.
Speaker 2:Okay, yes, and recruiting those respiratory muscles very early on yes, absolutely, and you know it also depends on the patient. You've got massive lung contusion, that's like ARDS and they may take 10-12 days before they are weaned sufficiently that you can do spontaneous breathing trials. And that's the challenge. These spontaneous breathing trials and the sedation holds have prerequisites and people are inclined to forget those prerequisites and they just say, oh, no, you've got to wake the patient up and test them. No, he's on 70 oxygen, he's still on full ventilation. Uh, you know, his lungs are still crappy. You can't actually do the test, the spontaneous breathing test, on him because he doesn't meet the prerequisites.
Speaker 1:Yeah, exactly.
Speaker 2:As you say, that's what one has to keep in mind.
Speaker 1:Yeah, and that's where the individualized assessment of patients and identifying their personal needs really comes into play, from a medical point of view, but also from a physiotherapy point of view, as we manage those patients in the ICU. Talking of which, what is your sort of expectation of the physiotherapists that work in your unit?
Speaker 2:Well, I mean I say this to them on ward rounds is that they are the most important person in helping to get the patient out of ICU. Because you know them doing, even if it's non-cooperative mobility of joints, even if it's just helping the patient to be properly suctioned, providing chest physiotherapy as the patient wakes up, you know teaching them to take deep breaths. And again, for the patients with polytrauma, once the orthopods have put in the metal work, you know getting the patient up and moving. You know we're inclined to forget that people lying in bed, you know bed rest in trauma is not good for you. You lose core muscles, especially if it's an older patient.
Speaker 2:They have all the complications of frailty. You have the risk of ventilator-associated pneumonias. You have the risk of deep vein thrombosis. Pneumonia is you have the risk of deep vein thrombosis Even with prophylaxis the incidence, especially if you're not able to measure your levels with sort of anti-TNA levels in trauma patients. We know they need higher levels of anticoagulation so their risk for DVT is higher, especially if they've got lower lung fractures. So there's a lot of factors that are sort of acting against the patient in terms of his recovery. So not only the physiotherapist but also the occupational therapist, the dieticians, the psychologists, if you have access to them, they're all part of the team and certainly as the patient starts waking up and gets off their neuroprotective phase, they become very important in the management of these patients.
Speaker 1:Yes, no, that's definitely true. So do you do ward rounds with the multidisciplinary team in the unit?
Speaker 2:At least once a week. Yes, we have At least once a week. We have a multidisciplinary ward round but the consultants whoever's the consultant on call will have close interaction on the other days, particularly with the dietitian um. They normally join us for part of the round every day but they're covering three or four icu's so that's sometimes difficult. We generally have one designated physiotherapist for the for the trauma icu at any one point of time, so we will primarily liaise with that person and most of the time they're in the unit in the morning when we're doing our rounds anyway and will join us or give inputs where they can, and then they will hand over or communicate with the other members of the physio team. That often, once the work in the wards is done they'll come and help the ICU people and luckily we also have the students from the, from the university, and then it's great when they're there, because then you suddenly have four or five physios in a in your 10 bed ICU and all of a sudden makes mobility and mobilization a whole lot easier.
Speaker 1:Yes, definitely, and a great exposure for them and addition to their clinical training. So that's great by the time your patients have stabilized and they are ready to go home. Are there any particular patients that you refer to an outpatient clinic or that you follow up after discharge?
Speaker 2:Yeah. So our burn patients we have a burns clinic that will follow them up, usually for between eight months and a year, and so they've often got skin grafts and things. Once they're ready to go out of ICU they will go to the general burn wards and then they'll have their skin grafts and everything and then they will get followed up at the clinic. And then from time to time we have specific polytrauma patients where we've maybe brought out stomas or they've had a laparotomy. They're good to go home but they're not good to have, not be followed up. So those we'll bring back to the trauma area and we see them as outpatients there.
Speaker 2:We don't have a specific outpatient clinic for trauma and obviously between. So a lot of our patients because we're a quaternary central hospital a lot of our patients we don't have a general ward for trauma Once they're ready to leave ICU they step down to their base hospitals. So then the teams of physios and OTs and allied health workers and everybody else at the base hospitals take over that acute rehabilitation hospitals take over that acute rehabilitation. Our biggest challenge in KwaZulu-Natal and I think in state practice countrywide, is a lack of inpatient residential rehabilitation facilities.
Speaker 2:You know there's no net care, rehab or Entebbe rehab or alliance health centers that are spread around the state sector. So in KwaZulu-Natal we have one hospital that's mainly set up for stomas and wounds, where they follow up, the sort of central Durban, and then there's one sort of chronic care hospital, but if you're lucky they'll have one bed available every nine months. So getting patients to what they really need. You don't want them blocking acute care beds. But some patients are just not right to go home, especially if their home is an informal settlement and you know, let's say, they need a wheelchair. Who's going to teach them to use the wheelchair? Who's going to teach them to transfer, even if they've been taught to transfer, who's going to be there to make sure that they can get through all the little corridors and the?
Speaker 2:washed away pathways and things like that. So you need that facility, which the private sector is very blessed with. And that's probably our biggest challenge is we spend so much money doing the acute care and some of our patients end up going home and never really reintegrating into community because they don't have the facilities.
Speaker 1:Yeah, no, that's very true and quite unfortunate in our country. Quite unfortunate in our country. And one can hope that maybe when the new health care policy comes into place the national health insurance that there would be some provision for this type of care in the public sector. But I guess we'll just have to wait and see.
Speaker 2:We will have to wait and see and live in hope guess we'll just have to wait and see.
Speaker 2:We will have to wait and see and live in hope. Yeah, and that kind of brings brings up the whole point of 90 percent of trauma is preventable. You know, and if, if you, if you don't get injured in the first place, you've got a much better chance of remaining productive. Um, I always, I always on ward rounds, say to the medical students with our, with our pediatric trauma, children must be seen and not hurt. Yes, and and so it's all those things like visibility. The guys are near a school, they must slow down. You know, I understand why people want a 30, 30 kilometers an hour um speed limit around schools, because that's where the kids get knocked. Or going to the. You know, a three-year-old should not be having to go to the, to the spaza, on their own to buy chips.
Speaker 2:There should be a senior trained adults or experienced adult going with them and it's all those, those bigger social issues that that can lead to that that lead to trauma. That can be areas where we can work on prevention. You know, the don't drink and drive is one aspect, um, you know, with with marijuana being a bit more liberally legal, it's more a case of don't smoke and fly these days, but it's also things like gun control and teaching people, emotional intelligence and infrastructure development. You know, having access, timely access to suitably equipped facilities. You know, having access, timely access to suitably equipped facilities. You know, because out in the smaller rural areas, the district hospital, if you're lucky, will have one ventilator. You ever many of us crash out in the rural areas. Patients will die for lack of facilities, not for lack of enthusiasm on the part of the clinicians. So there's many challenges that still face this country in terms of trauma. It's not just a yes, it is a surgical disease, but it's not just a surgical disease yeah, exactly, there's definitely some accountability from the community side.
Speaker 1:Um tim, as we draw to a close, uh, is there any other last thoughts that you would like to share with our physiotherapy audience?
Speaker 2:Sure, I would like to firstly say thank you to the physiotherapists because, as I said, they're an important part, if not one of the most important parts of the team parts of the team, I think, long term. I actually think the dietician is probably the person who has the longest interaction with the patients, because it takes up to two years for them to regain what they lose from the bed rest. But I think the physios and the OTs are probably next in line, but also our speech therapists, the social workers, the psychologists they do and probably, most importantly, even the nurses. They spend the most time with the patients. We as doctors come in, make surgical decisions, make ICU decisions, write the orders and we go back to our offices and, unless there's chaos reigning, we're not going to be called back to the bedside urgently for the next hour or three, whereas the physios and the OTs and the nurses and everybody, they're there six, eight, 12 hours a day and they're an important part of the team and they're a valued part of the team.
Speaker 2:So thank you is what I'd say.
Speaker 1:Thanks so much. And thank you very much for your time, Professor Hartcastle. I don't think this is the last time we'll see each other for this podcast series, but thank you so much for your time today. It's much appreciated.
Speaker 2:It's a pleasure.
