A keystone speciality: The role of anaesthesia in trauma systems

The neglected burden of trauma

Trauma is an invisible pandemic, responsible for more deaths globally than malaria, tuberculosis and HIV combined. ¹ Alarmingly, in low and middle-income countries (LMICs) this burden is increasing. Diverse drivers include an increasingly elderly population, rising automobile use, conflict and natural disasters. Soberingly, more than 90% of the deaths from injury occur in LMICs ² and for those who survive, there can be significant and long-lasting physical and psychological consequences alongside profound economic and societal impacts on both current and future wage earners.

Trauma systems in resource-poor countries

Trauma is not only a concern for LMICs, and remains a leading cause of death in the first four decades of life in high-income countries (HICs). ³ However, in those countries which have invested in nationwide ‘trauma systems’, there is improved mortality in patients who survive in hospital.^4–6 The wider health system around trauma care is broader than often conceptualised, encompassing health-seeking behaviour and beliefs, public health and pre-hospital measures, acute care, rehabilitation and social care, ⁵ all essential components of a functioning system to enable patient survival.^4,6 Indeed, rather than the linear pathway often used to describe trauma care, traumatic injury can instead be viewed as the start of a complex, circular, patient journey which begins and ends in the community having passed through the acute care system.

Many of the trauma systems in HICs evolved from military experience and research, with the role of dedicated trauma teams and damage control resuscitation being two such examples. ⁵ LMICs seeking to improve trauma systems with limited resources at their disposal face the challenge of choosing not only which elements of the trauma system to invest in, but how best to configure them given their pre-existing healthcare infrastructure. Within HICs there remains a diversity of approaches to trauma system design, with no universally agreed approach. This is due to historical, political, organisational, cultural and even linguistic factors. ⁷ Even the richest nations show heterogeneity in their approach to trauma systems, both between and within countries.^8,9

LMIC health systems, frequently embedded in fragile or uncertain governmental structures, are confronted with a number of obstacles to improvement. Co-ordination both within and between healthcare institutions can present a significant challenge in resource-limited settings, who also face the greatest need. In response to this, the World Health Organisation's Eastern Mediterranean Regional Office established the Trauma Operational and Advisory Team (TOpAT) in 2020, created in part to advise WHO partner countries on the development of contextualised trauma systems.

Anaesthesia at the heart of the trauma team

The multidisciplinary trauma team forms the core of the trauma response to a patient presenting to the emergency department with significant injury. This team consists of emergency department physicians and nurses alongside speciality doctors, including surgeons, anaesthesiologists and intensivists. A designated team leader, frequently the most senior clinician present, assumes a ‘hands-off’ coordinator role.

The anaesthesiologist is an essential member of the trauma team in most HICs.^10,11 Major trauma presents several challenges, with a need for focus on the non-technical skills required to work in an unfamiliar team under difficult circumstances. ¹¹ Alongside clinical skills, the anaesthesiologist must also demonstrate expertise in soft skills such as leadership, management and decision-making. Anaesthesiologists traditionally have experience in all aspects of a trauma patients’ pathway – at the point of injury, in the operating theatre, intensive care and in chronic pain management. This gives them a rare and valuable insight into the holistic approach to trauma patient care.

Non-physicians in anaesthesia

A key challenge emerging from the TOpAT's work is the lack of medically qualified anaesthesia providers. ¹² Anaesthesia is provided globally by a variety of clinical cadres including physicians, nurses, and non-physician anaesthetists (NPAs) who may have neither medical nor nursing qualifications. These cadres also interact in a variety of ways within different cultural and regulatory frameworks, but frequently have no clinical autonomy or authority.

The TOpAT have identified a historical lack of awareness of the role played by anaesthesiologists by government and disease-specific transnational healthcare initiatives. In many HICs, anaesthesia is the single largest hospital speciality. ¹³ Despite this, the speciality often tends towards invisibility to patients and even to other members of the clinical team. Despite the 2017 Lancet Commission on Global Surgery finding that more than 5 billion people lack safe and affordable access to surgical and anaesthesia care when needed, ¹⁴ this has still not translated into the necessary funding and attention at the global level.

More recently, the shortage of anaesthesiologists during the SARS-CoV2 pandemic has spurred some governments to pay closer attention to this issue. The experience of the TOpAT suggests that governments are becoming aware of the value of anaesthesiology across the acute healthcare system, beyond the operating theatre to trauma, critical care and maternity services.

The challenges of developing anaesthesia as a speciality

Developing an anaesthesia workforce is complex and the role of non-physicians has been fundamental in the provision of safe surgery in many countries. NPAs are an essential component of addressing access to safe perioperative anaesthesia in resource-limited settings: elective and emergency anaesthesia may be provided by nurses or technicians, working independently or under the direct supervision of surgeons.

However, even in healthcare systems where anaesthesia is provided by non-physicians, there is broad consensus that services should be led by a physician anaesthesiologist. ¹⁵ The need for physician-led care becomes even more marked in the delivery of intensive care, major trauma or the management of traumatic brain injury, where a greater depth and breadth of medical training is required alongside decision making, team management and leadership skills. An appropriately trained physician-led workforce is essential to the development of sustainable trauma systems, a view that is echoed by the WHO and World Federation of Societies of Anaesthesiologists (WFSA). ¹⁵

Despite this obvious need, efforts to improve the number of anaesthesiologists on a global scale are hampered by the time and expense required to deliver postgraduate anaesthetic training, when compared to NPA training schemes.

Anaesthesiology as the future of trauma care

The rapid need for critical care expansion during the SAR-CoV2 pandemic highlighted that expanding the role of anaesthesiologists will have a positive, cross-cutting impact beyond the operating theatre. ¹⁶ The need to contextualise health services to a cultural and resource-specific setting requires local leadership to drive service change and pursue clinical excellence.

Perioperative care, critical care and trauma services will be best served in the long run by governmental investment in greater numbers of anaesthesiologists in dedicated post-graduate training programmes to train a future generation of clinical leaders. Where the recent pandemic has focussed the need to bridge the gap in the global anaesthesiology workforce, the ongoing and vastly more dangerous pandemic of traumatic injury requires a sustained global response.

At the same time, a balance must be struck between immediate and long-term development. NPAs have a vital role to play now and in the future; improving their ability to function within the trauma team must be embraced through access to further training and professional development. However, expansion of NPA roles comes with a note of caution, that a short-term solution should not inadvertently stifle future efforts at speciality development. Medical providers have a wider role than direct clinical care – they are responsible for development of a service and act as political advocates. This is not a role that can be simply re-allocated to a non-medical provider.

The success of NPAs in delivering safe perioperative anaesthesia can be argued as an existing barrier to development of an anaesthesiology-led workforce. It is the belief of these authors that expansion of the NPA workforce should occur in parallel with the longer-term goal of increasing the number of anaesthesiologists. This would serve to improve access to safe surgery and anaesthesia care, but more importantly would enable expansion of the speciality into delivery of quality trauma care, working towards closing the gap in trauma outcomes around the world.

Conclusion

The global burden of trauma is high and rising, with the greatest impact being felt in resource poor and emerging economies. This burden is only likely to be addressed through the development of integrated trauma systems, with a focus on both public health prevention and coordinated acute care services. Anaesthesiology is fundamental to the future of trauma care, a speciality often overlooked and critically underpopulated in the global south. Governments wishing to strengthen their trauma systems must urgently review their ability to recruit and train anaesthesiologists to deliver coordinated emergency, perioperative and critical care to survivors of traumatic injury.