438

Comment

and the square root of 21 is not a whole number, the stated ISS of 25 cannot be correct. The use of level of consciousness in the coding of four of these patients is also disturbing. This should only be used when no anatomical information is available, even though use of loss of consciousness may be tempting as it can lead to higher scores. In any prospective study the anatomical injury ought to have been specifically defined. Coding has definite rules, and it is our experience that the clinicians involved in a patient's care are not necessarily dispassionate in applying the criteria. It would be interesting to know the scores given to these patients on their MTOS(UK) returns. The objective of scoring is to provide a uniform way of describing injuries, which can only be achieved by obeying the rules. This skill requires training and practice. A course to teach the correct approach to scoring is currently available under the aegis of MTOS(UK), as there are many pitfalls for the unwary. F W CROSS FRCS Consultant Surgeon T J COATS FRCS HEMS Registrar C J C KIRK TD FIMLS HEMS Data Manager The Royal London Hospital Whitechapel, London The above study (Annals, May 1992, vol 74, p212) was carried out using AIS 80, rather than AIS 90. The only specific mistake in the article concerning probabilities for survival and outcome is Case 13, where the injury severity score is indeed, 25. Mr Nayeem's reply details the other points. Further, it should be pointed out that the MTOS (UK office) recommends the use of AIS 85, rather than AIS 90, for TRISS methodology. It should also be pointed out that as far as the above cases are concerned, AIS 85 differs from AIS 80 in only one respect, inasmuch that, a basal skull fracture with CSF leak would score 4 in AIS 80, but only score 3 in AIS 85 (the Abbreviated Injury Scale 1985 Revision, page 30). However, the assessor's comment "not only is it important to improve facilities in district general hospitals, it is also important to centralise trauma care and improve the teaching of the management of trauma, eg ATLS Certification, while continually highlighting how we could have done better" still stands. The Royal London Hospital does encourage the centralisation of trauma care by virtue of the helicopter emergency medical service and, furthermore, they run three ATLS courses a year. Lastly, teaching hospitals have higher staffing levels than district general hospitals and the latter must be encouraged to frankly report their work, especially as the majority of the 256 accident and emergency departments in the UK, are district general hospitals, rather than teaching hospitals. R TOUQUET RD FRCS

Consultant in Accident & Emergency Medicine St Mary's Hospital London I read with interest the paper by Nadeem Nayeem et al. (Annals, May 1992, vol 74, p212) and would like to congratulate them on their results but would take issue with their conclusions. In a 1-year experience, they admitted 184 patients with a diagnosis of trauma of whom 27 were noted on

retrospective analysis to have an injury severity score of 16 or more, identifying them as victims of major trauma. Of these 27 patients there were six deaths, one of which was identified as preventable. Using the same TRISS methodology they identified two patients who were unexpected survivors. These data are compatible with high-quality trauma care but I question whether they are, in fact, representative of all hospitals providing trauma care in the United Kingdom. The Luton and Dunstable Hospital has had a strong tradition of excellence in the care of trauma patients since the opening of the Ml motorway, and I would venture that its expertise in this area exceeds that of other institutions. Finally, their questioning the need for the instigation and designation of trauma centres is somewhat invalidated by their subsequent recommendations for trauma care, namely timely intervention by experienced clinicians and the ready availability of diagnostic and operating room resources since these are the very criteria defining a trauma centre. If Britain's health care services are truly committed to reducing preventable death from trauma, then the designation of trauma centres and implementation of trauma systems is a necessary and pressing priority. The validity of this concept has been proven time and again, and has been further exemplified by my own experience in San Diego County where the preventable death rate has been reduced to 2% since instigating a trauma system 8 years ago. RICHARD K SIMONS FRCS FRCSC

UCSD Medical Center San Diego, California

Attending Trauma Surgeon

Authors' reply Thank you for giving us an opportunity to reply to Mr Cross and his colleagues' letter. The scoring system use in this study was based on the Abbreviated Injury Scale 1980 revision (AIS 80) as the study was done in 1989-1990. Our reply to specific points raised in this letter are as follows: 1. ISS (Injury Severity Score) is worked out from the highest AIS in three anatomical regions. a) Head and Neck b) Abdomen and pelvic contents c) Bony pelvis and limbs d) Face e) Body surface therefore bony injury and skin lacerations are scored separately to work out ISS. (In AIS 90 skin lacerations are ignored if the patient has any injury which has a higher score in that anatomical region) 2. Case 24. Fracture of the base of the skull with CSF leak has an AIS score of 4 and hence the total ISS of 16 (whereas fracture of the base of the skull without CSF leak has an AIS score of 3).

Similarly case No. 9 has an ISS score of 20. Case 19. We would agree that the ISS is 48 rather than 50 but this does not affect the probability of survival or the outcome in this case. Case 8. LeFort II fracture is AIS score of 3 and not 2 as mentioned in Mr Cross's letter. A fractured femur is AIS 3 and a subdural haematoma which is more than 100 cc is AIS 5, therefore, (3) + (3) + (5) = 43 which is what the patient scored. 3. We would agree about cases 13 and 15 coding and accept that the correct ISS for these cases should have been 25 and 38 respectively.

Care of road traffic accident victims in a district general hospital.

438 Comment and the square root of 21 is not a whole number, the stated ISS of 25 cannot be correct. The use of level of consciousness in the coding...
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