1. Trauma Through the Ages
Grant Christey
MTS Symposium
5 April 2019

2. Today Epochs of Trauma Ebb and flow of medicine and nursing
The advances
The doldrums
What next

3. Epochs Prehistoric 120,00BC – 3000BC Early Civilizations
3000BC -200AD
Egyptians, Greeks, Romans
Dark and Middle ages; Middle East
Renaissance
Post Renaissance
The Wars
1840-present

4. Prehistoric (before 3000 BC)
162 Prehistoric skeletons from California
10% long bone fractures
4.4% cranial injuries including missiles
Interpersonal violence was common
Neolithic German farmers (7K BC)
Skull injuries
Spear tips
Fractured tibias
Men and children
Neanderthal vs Paleolithic
(rodeo mystery solved)

7. Early Civilisations 3000BC-200AD
Egyptians
Greeks
Romans
South America
Eastern Europe

8. Egyptians 3000-2000 BC Bandages, Beer Magic Sharp things
Edwin Smith Papyrus BC
Imhotep and the pyramids
48 trauma cases
Only one mystical cure
Examination, diagnosis, treatment
Outcome Options: favourable uncertain, no hope

9. Greeks Hippocrates 480BC Aristotle 384BC Nurses
Applied a systematic approach to medicine
Humoral Imbalance Theory: blood, yellow bile, black bile, phlegm
Theory dominated for almost 1000 years
Hippocratic Oath
Aristotle 384BC
“Man is an animal” so can be dissected
Soul higher than man:
Anatomy flourished
Bridge between anatomy and science
Nurses
Organised nursing in sanitariums
“Therapainis” = maid or servant that provided care

10. Romans Celsus 25BC – 50 AD Galen 165 AD Used anatomic knowledge
Pioneered open wound care
open fracture management
Galen 165 AD
Physician to Marcus Aurelius
Dissected different animals
Confused everyone
Errors persisted until Vesalius in 1540
“Said everything that could be said”
Caracalla Baths 100AD

11. Nurses in Ancient Rome Deaconesses cared for the elderly and needy
Deaconess Order is first organised district nursing service
Roman matrons held in high esteem, founding hospitals and monasteries
In 350AD Fabiola, a roman matron erected a house for the sick and injured; the first public hospital
Christianity fuelled the importance of nursing while inhibiting medicine through the Middle and Dark ages.

12. Trepanation in South America
BC: long term survival 40%
AD: long term survival 91%
(Inca period): 80%
(American Civil war: 50%)

13. Trepanation in Eastern Europe
Neolithics 10k-7kBC developed sharp tools
3000BC (Copper age in Russia)
Obellion defect into superior sagittal sinus
Not a great strategy for SDH but dura usually intact
1500: Craniectomy popular for surgeons. No anaesthetic

14. Dark and Middle Ages 200-1500 AD In Europe In the Middle East
Rome fell
Catholic church suppressed science and heresy
Western medicine stalled for 1300 years
In the Middle East
Mixtures of mysticism and innovation
Avicenna (Arab) published “the Canon of Medicine” in 1025
Bits of Hippocrates, Aristotle and Galen
the go-to text until 1600s
Mutual interactions of body elements
“The temperament of the coldest member by level of moisture is the serious humour”

15. Renaissance 1400-1600 Vesalius was the hero Understood Greek and Latin
Wrote “De Humani Corporis Fabricus” in 1543
Utilised dissection as a primary teaching tool (mostly dead criminals)

16. Rennaisance Ambroise Pare War surgeon
Used ligatures when he ran out of hot oil in the Seige of Turin 1537
Huge reduction in infections and amputations
Successful trauma surgery
Lead bullet extraction tools
Plastic surgical techniques

17. Post-Rennaisance Acceleration
John Hunter 1728
Scottish surgeon: Pioneered modern surgical techniques based on anatomy
“Don’t think, try the experiment”
Dominique Larrey (Napoleon’s Surgeon)
Flying Ambulance at Waterloo 1797
CPR was born
Dutch Society for the Recovery of Drowned Persons 1767
Charles Kite FRS 1788 “An Essay on the Recovery of the Apparently Dead”
Ist successful defibrillation on 3 year old after a 3rd floor fall

18. Larrey’s Flying Ambulance 1797

19. The Dawn of Modern Nursing 1850
Florence Nightingale: the lady of the lamp in the Crimean War 1854
The symbolic figure of modern nursing: stubborn opinionated
Inspired by hospital visits with her mother to improve care
Established St Thomas nursing school
Sanitary reform
Hunger relief in India
Pioneer in medical infographics
Mystical novelist

20. American Civil War 1861-1865 Ist modern war
Docs got 2 years at Med School
Lead bullets than flatten on impact
Little anaesthesia at the beginning (more up north)
Morphine powder into wounds, opium pills or whisky
Then chloroform (35 deaths in 80,000 cases)
60,000 amputations; anaesthetic time 15 minutes
Letterman’s Ambulance Plan: no-one left on the field at Gettysburg

23. Nurses in the Civil War Florence’s influence strong
Transitioned from untrained to trained
Established first permanent nursing corps
Change from welfare organisations to scientific
Greater responsibility and autonomy
George Washington: 1 nurse/10 patients; 1 matron/100 patients

24. WW1 1914-1918 Major advances in trauma surgery and survival
Antiseptics in surgery
Inhalational anaesthesia
Battel field evacuation
Diagnostic X-Rays
Saline via hypodermic trocar
1 anaesthetist per patient

25. WW1
Casualty Clearing Station

26. WW
Rapid haemostasis: mortality from 1-8 hours is %
Started the concept of the “Golden Hour”
Guedel designed his airway and dunked his dog

27. Between the Wars IV Anaesthesia Penicillin Fluid Therapy
1934 Johnathon Lundy used thiopentone via a piston syringe
(Similar to those recovered from the Mary Rose sunk in Portsmouth Harbour in 1542)
Penicillin
discovered by Alexander Fleming in 1928
mass production started in 1942
Fluid Therapy
Advances driven by new knowledge of physiology

28. WW2 1939-1945 Antibiotics (thanks Alexander) Delayed Closure
Sophisticated evacuation
PTSD
Birmingham Accident Hospital is 1st trauma centre
Separate the ill from the injured
Single team from admission to discharge
Care directed by senior surgeon
Rehab is integral to care and starts at admission

29. After some more wars.... 1950s: Fluid Therapy 155-1975 Vietnam war
Electrolyte solutions
Balanced fluid administration
Vietnam war
Many advances
Nurses provide complex care; amputations, wounds
1980s: Monitored Resuscitation
Damage control surgery
Advances in critical care medicine
New medicines
1990s
Trauma systems are established ”Two County Study”
2000s
Emergency non-invasive techniques
Rapid imaging
System analytics and improvement

30. Now and beyond..
Seamless, high quality care through the whole patient journey
Whole system quality assessment and monitoring
Targeted risk reduction from incidence and treatment
Evidence-based change
Patients first!
Assisting trauma patients to the life that is meaningful for them