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Death of children with head
injury SIR,-It is refreshing to have people from another discipline examine results of the management of trauma. Few would disagree with the conclusions of Dr P M Sharples and colleagues that the care of patients with serious injury could be improved.' Problems in managing the airway and missed diagnoses are common themes in such studies. I hope that training in management of trauma will reduce the errors made concerning patients who reach hospital alive. Training is not, however, the only problem. The authors rightly point out that transfer of patients with trauma is a serious undertaking. On the other hand, many hospitals still do not have a computed tomographic scanner-an essential tool in the care of patients with serious head injury. (It is not only small hospitals that do not have this facility: there is at least one teaching hospital with 1000 beds that does not.) Dr Sharples and colleagues discuss the problems of prehospital care. Do they have any evidence as to the tinre that aspiration occurred in those who aspirated?'How many of the 58 children with fatal injury or who were pronounced dead at the scene had evidence of aspiration into the lungs? The provision of resources for out of hospital rescue services is woefully inadequate. Given current funding and staffing restrictions, there are great logistical problems in providing immediate care by personnel capable of anaesthetising and performing endotracheal intubation in seriously injured children at the roadside. Perhaps the current trials of immediate helicopter aid2 may go some way to answering these problems. Dr Sharples and colleagues state that the guidelines on management of patients with head injury may not have been sent to paediatric departments. As stated in the title of the paper these guidelines were for "the initial management after head injury in adults."' The initial management of major trauma is probably one of the most difficult aspects of medical practice. Unfortunately it has been starved of finance, staff, and research funds. There are some signs that attitudes are changing. The Royal College of Surgeons has recently taken major steps in promoting training in emergency care (the introduction of the advanced trauma life support course and the diploma in immediate care). Alternative methods of organising such care are being evaluated. Many of the staff concerned in the care of patients with serious injury are trying to improve the standards of management. Studies such as that of Dr Sharples and colleagues add further weight to the efforts to bring about this complicated task. J WARDROPE
Accident and Emergency Department, Northern General Hospital, Sheffield S5 7AU
534
1 Sharples Phi, Storey A, Aynsley-Green A, Evre JA. Avoidable factors contributing to death in children with head injury. BrMedJ 1990;300:87-91. (13 Januarv.) 2 Delamothe F. Here come the helicopters. Br Med J 1989;299: 639. (9 September.) 3 Group of Neurosttrgeons. Guidelines for the initial management after head injury in adults. BrMedJ 1984;288:983-5.
SIR,-The introduction of crown immunitymeaning crown responsibility-and the recent audit of head injury in children by Dr P M Sharples and colleagues' afford an opportunity to reappraise some aspects of medical training. It is a sad fact that there is an appalling deficiency in resuscitation knowledge and skills among junior house staff.2 Furthermore, intensive care units receive a steady stream of patients whose morbidity and mortality are considerably increased by iatrogenic factors-that is, medical mismanagement of resuscitation and transfer of patients. A common example, shown by Dr Sharples and colleagues, is the exacerbation of minor primary neurological injury after head injury by the secondary injuries of hypotension, hypoxia, hypercarbia, and raised intracranial pressure due to coughing, straining, and respiratory obstruction. Comatose patients with trauma are all too commonly erroneously transferred unintubated, breathing spontaneously through a small tube, and accompanied only by a nurse or a senior house officer from the orthopaedic department. Published audits of head injury and trauma indicate avoidable factors in 35-54% of patients who die.' 'I Rarely are relatives made fully aware of these errors of judgment (and education) and these aspects of substandard care that have contributed to the predicament of their family member. If we are to be completely honest with our patients many more medicolegal cases will arise from errors in resuscitation and transfer of patients. These errors are a direct result of deficiencies in training in the philosophy and practice of airway, breathing, and circulation -the ABC of resuscitation. Training in resuscitation and anaesthetic skills receives minimal attention in most medical schools in each house year (typically one to four weeks). Surely in the 1990s such exposure to resuscitation skills in six years of training is inadequate? Three months spent learning these skills during an anaesthetic attachment in the house year for at least some house officers would surely be no less useful than a similar period in ophthalmology, dermatology, or orthopaedic departments? If anaesthesia remains a career postgraduate subject then we deprive the newly qualified doctor of the opportunity of obtaining any appreciable exposure to resuscitation problems and clinical experience in the skills. In Australasia most graduates spend three months in anaesthesia and intensive care departments, and in my experience the quality of resuscitation skills is notably higher there than in the United Kingdom.
No doubt three months in an anaesthesia department would produce many logistic problems, but postgraduate experience is valuable and training must evolve to suit changing needs. Three months would be adequate to instil the basics of resuscitation skills, outline the problems and difficulties, show the limitations of inexperienced doctors, and indicate the need for help and how best to obtain it. If common sense and reasoned argument fail to convince of the value of postgraduate clinical training in resuscitation skills then the NHS will foot the increasingly large bill for medicolegal settlements. That would be not only tragic for the patients and their families and exponentially expensive but also an appalling example of the abdication of responsibility for appropriate clinical training and certainly a missed opportunity for preventive medicine. P J McQUILLAN Nuffield Department of Anaesthesia, John Radcliffe Hospital, Oxford OX3 9DU I Sharples PM, Storev A, Avnsley-Green A, Eyre JA. Avoidable factors contributing to death of children with head injury.
BrMedJ3 1990;300:87-91. (13 January.) 2 Skinner DV, Camm AJ, Miles S. Cardiopulmonary resuscitation skills of preregistration house officers. Br Med J 1985;290: 1549-50. 3 Jeffreys RV, Jones JJ. Avoidable factors contributing to the death of head injury patients in general hospitals in Mersey region. Lancet 1981;ii:459-61. 4 Anderson ID, Woodford M, de Dombal FT, Irving M. Retrospective study of 1000 deaths from injury in England and Wales. Br MedJ 1988;296:1305-8.
SIR,-We would like to make two comments on the paper by Dr P M Sharples and colleagues. Firstly, the statement that three children with cerebral oedema at necropsy had no other evidence of appreciable brain injury cannot be accepted in this unqualified fashion. Unless detailed neuropathological examination of these brains was undertaken it is highly likely that features of diffuse axonal injury may have been missed, and this is particularly likely to have been the case if the brains were sliced when fresh and without prior fixation as part of a coroner's necropsy. Criteria for including these children in the avoidable death group are questionable in the absence of any details on the quality of pathological examination of the brains and in particular histological evidence of hypoxic neuronal damage. Secondly, the finding at necropsy of aspirated gastric contents after major trauma is not uncommon, particularly in victims of trauma with few evident injuries who may have been exposed to intense resuscitative procedures before intubation and protection of the airway. Faced with a child who has died with extensive injuries there will be undoubted bias for the pathologist not to record aspiration of gastric contents as being important as there would be abundant other evidence of trauma
BMJ VOLUME 300
24 FEBRUARY 1990
Death of children with head
injury SIR,-It is refreshing to have people from another discipline examine results of the management of trauma. Few would disagree with the conclusions of Dr P M Sharples and colleagues that the care of patients with serious injury could be improved.' Problems in managing the airway and missed diagnoses are common themes in such studies. I hope that training in management of trauma will reduce the errors made concerning patients who reach hospital alive. Training is not, however, the only problem. The authors rightly point out that transfer of patients with trauma is a serious undertaking. On the other hand, many hospitals still do not have a computed tomographic scanner-an essential tool in the care of patients with serious head injury. (It is not only small hospitals that do not have this facility: there is at least one teaching hospital with 1000 beds that does not.) Dr Sharples and colleagues discuss the problems of prehospital care. Do they have any evidence as to the tinre that aspiration occurred in those who aspirated?'How many of the 58 children with fatal injury or who were pronounced dead at the scene had evidence of aspiration into the lungs? The provision of resources for out of hospital rescue services is woefully inadequate. Given current funding and staffing restrictions, there are great logistical problems in providing immediate care by personnel capable of anaesthetising and performing endotracheal intubation in seriously injured children at the roadside. Perhaps the current trials of immediate helicopter aid2 may go some way to answering these problems. Dr Sharples and colleagues state that the guidelines on management of patients with head injury may not have been sent to paediatric departments. As stated in the title of the paper these guidelines were for "the initial management after head injury in adults."' The initial management of major trauma is probably one of the most difficult aspects of medical practice. Unfortunately it has been starved of finance, staff, and research funds. There are some signs that attitudes are changing. The Royal College of Surgeons has recently taken major steps in promoting training in emergency care (the introduction of the advanced trauma life support course and the diploma in immediate care). Alternative methods of organising such care are being evaluated. Many of the staff concerned in the care of patients with serious injury are trying to improve the standards of management. Studies such as that of Dr Sharples and colleagues add further weight to the efforts to bring about this complicated task. J WARDROPE
Accident and Emergency Department, Northern General Hospital, Sheffield S5 7AU
534
1 Sharples Phi, Storey A, Aynsley-Green A, Evre JA. Avoidable factors contributing to death in children with head injury. BrMedJ 1990;300:87-91. (13 Januarv.) 2 Delamothe F. Here come the helicopters. Br Med J 1989;299: 639. (9 September.) 3 Group of Neurosttrgeons. Guidelines for the initial management after head injury in adults. BrMedJ 1984;288:983-5.
SIR,-The introduction of crown immunitymeaning crown responsibility-and the recent audit of head injury in children by Dr P M Sharples and colleagues' afford an opportunity to reappraise some aspects of medical training. It is a sad fact that there is an appalling deficiency in resuscitation knowledge and skills among junior house staff.2 Furthermore, intensive care units receive a steady stream of patients whose morbidity and mortality are considerably increased by iatrogenic factors-that is, medical mismanagement of resuscitation and transfer of patients. A common example, shown by Dr Sharples and colleagues, is the exacerbation of minor primary neurological injury after head injury by the secondary injuries of hypotension, hypoxia, hypercarbia, and raised intracranial pressure due to coughing, straining, and respiratory obstruction. Comatose patients with trauma are all too commonly erroneously transferred unintubated, breathing spontaneously through a small tube, and accompanied only by a nurse or a senior house officer from the orthopaedic department. Published audits of head injury and trauma indicate avoidable factors in 35-54% of patients who die.' 'I Rarely are relatives made fully aware of these errors of judgment (and education) and these aspects of substandard care that have contributed to the predicament of their family member. If we are to be completely honest with our patients many more medicolegal cases will arise from errors in resuscitation and transfer of patients. These errors are a direct result of deficiencies in training in the philosophy and practice of airway, breathing, and circulation -the ABC of resuscitation. Training in resuscitation and anaesthetic skills receives minimal attention in most medical schools in each house year (typically one to four weeks). Surely in the 1990s such exposure to resuscitation skills in six years of training is inadequate? Three months spent learning these skills during an anaesthetic attachment in the house year for at least some house officers would surely be no less useful than a similar period in ophthalmology, dermatology, or orthopaedic departments? If anaesthesia remains a career postgraduate subject then we deprive the newly qualified doctor of the opportunity of obtaining any appreciable exposure to resuscitation problems and clinical experience in the skills. In Australasia most graduates spend three months in anaesthesia and intensive care departments, and in my experience the quality of resuscitation skills is notably higher there than in the United Kingdom.
No doubt three months in an anaesthesia department would produce many logistic problems, but postgraduate experience is valuable and training must evolve to suit changing needs. Three months would be adequate to instil the basics of resuscitation skills, outline the problems and difficulties, show the limitations of inexperienced doctors, and indicate the need for help and how best to obtain it. If common sense and reasoned argument fail to convince of the value of postgraduate clinical training in resuscitation skills then the NHS will foot the increasingly large bill for medicolegal settlements. That would be not only tragic for the patients and their families and exponentially expensive but also an appalling example of the abdication of responsibility for appropriate clinical training and certainly a missed opportunity for preventive medicine. P J McQUILLAN Nuffield Department of Anaesthesia, John Radcliffe Hospital, Oxford OX3 9DU I Sharples PM, Storev A, Avnsley-Green A, Eyre JA. Avoidable factors contributing to death of children with head injury.
BrMedJ3 1990;300:87-91. (13 January.) 2 Skinner DV, Camm AJ, Miles S. Cardiopulmonary resuscitation skills of preregistration house officers. Br Med J 1985;290: 1549-50. 3 Jeffreys RV, Jones JJ. Avoidable factors contributing to the death of head injury patients in general hospitals in Mersey region. Lancet 1981;ii:459-61. 4 Anderson ID, Woodford M, de Dombal FT, Irving M. Retrospective study of 1000 deaths from injury in England and Wales. Br MedJ 1988;296:1305-8.
SIR,-We would like to make two comments on the paper by Dr P M Sharples and colleagues. Firstly, the statement that three children with cerebral oedema at necropsy had no other evidence of appreciable brain injury cannot be accepted in this unqualified fashion. Unless detailed neuropathological examination of these brains was undertaken it is highly likely that features of diffuse axonal injury may have been missed, and this is particularly likely to have been the case if the brains were sliced when fresh and without prior fixation as part of a coroner's necropsy. Criteria for including these children in the avoidable death group are questionable in the absence of any details on the quality of pathological examination of the brains and in particular histological evidence of hypoxic neuronal damage. Secondly, the finding at necropsy of aspirated gastric contents after major trauma is not uncommon, particularly in victims of trauma with few evident injuries who may have been exposed to intense resuscitative procedures before intubation and protection of the airway. Faced with a child who has died with extensive injuries there will be undoubted bias for the pathologist not to record aspiration of gastric contents as being important as there would be abundant other evidence of trauma
BMJ VOLUME 300
24 FEBRUARY 1990
