|Year : 2020 | Volume
| Issue : 1 | Page : 44-49
Survey on knowledge of acute trauma care among trainee anesthesiologists
Malavika Kulkarni, Laxmi Shenoy, N Anitha, TK Sushma, Shwetha Sinha, K Rama Rani
Department of Anaesthesiology, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
|Date of Submission||25-Jul-2019|
|Date of Decision||25-Aug-2019|
|Date of Acceptance||29-Aug-2019|
|Date of Web Publication||13-Feb-2020|
Dr. Laxmi Shenoy
Assistant Professor, Department of Anaesthesiology, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka
Source of Support: None, Conflict of Interest: None
Background: Trauma is a major cause of morbidity and mortality in India. A trauma-related death occurs every 1.9 min, and the mortality in serious injuries is six times worse compared to a developed country.
Methods: The postgraduates were given a questionnaire with three sections. The first and second sections had questions pertaining to the participants' demographic data, their training, and their perceptions on training in trauma care. The third section contained ten multiple-choice questions designed to check their factual knowledge on basic trauma care. Their scores were rated as follows: poor (0–6), satisfactory (7–8), and excellent (9–10).
Results: All 146 participants were postgraduates. Fifty-five (37.7%) of them claimed to have undergone a formal training in the initial trauma management. The scores obtained by both trained and untrained respondents were very low. Only 30.9% of the trained postgraduates managed a score of ≥7. 87%, whereas the untrained ones had a score of <7. While nearly 19% of the specifically trained postgraduates scored 9–10, only 2.63% of the untrained ones did so. Two trained students and no untrained student got a score of 10.
Conclusion: The knowledge of trauma care among postgraduates is grossly inadequate to provide trauma care in acute trauma scenarios. Since training has shown to have better outcomes, such programs need to be incorporated in the postgraduate curriculum.
Keywords: Acute trauma care, advanced trauma life support, developing country, trainee anesthesiologists, training in trauma, trauma knowledge
|How to cite this article:|
Kulkarni M, Shenoy L, Anitha N, Sushma T K, Sinha S, Rani K R. Survey on knowledge of acute trauma care among trainee anesthesiologists. Indian Anaesth Forum 2020;21:44-9
|How to cite this URL:|
Kulkarni M, Shenoy L, Anitha N, Sushma T K, Sinha S, Rani K R. Survey on knowledge of acute trauma care among trainee anesthesiologists. Indian Anaesth Forum [serial online] 2020 [cited 2020 Feb 21];21:44-9. Available from: http://www.theiaforum.org/text.asp?2020/21/1/44/278184
| Introduction|| |
Trauma is a major cause of morbidity and mortality all around the world, accounting for 12% of disease burden worldwide. A vehicle accident is reported every 3 min on Indian roads. In India, a trauma-related death occurs every 1.9 min. It is considered that the mortality in serious injuries is six times worse in a developing country such as India compared to a developed country. Despite the increasing magnitude of the problem, the existing trauma care systems are far from satisfactory, being existent predominantly in Indian cities. The reasons for this may be lack of infrastructure, skilled, and dedicated trauma team in the prehospital and hospital setup. In addition, a formal standardized education program in trauma life support skills is not widely available in centers across India.
A training program such as advanced trauma life support (ATLS) program focuses on the rapid evaluation of patient's condition, resuscitation and stabilization, and transfer of a trauma victim to a facility with higher resources., ATLS is now widely accepted as the standard protocol for the initial assessment and treatment of acute trauma victims.,, Studies have shown that training in ATLS or similar programs improves the initial care given by the trainees in acute trauma situation.,
In most of the tertiary care centers, especially teaching hospitals, anesthesia residents are the first to be called to assess and resuscitate an acute trauma care victim. This survey was conducted to assess the knowledge of trauma care among trainee anesthesiologists who are often involved in the care of trauma victims.
Aims and objectives
The aims and objectives are to assess the level of knowledge of acute trauma care among trainee anesthesiologists and the necessity for incorporating trauma life support training in their teaching curriculum.
| Methodology|| |
After obtaining approval from the Institutional Ethics Committee, anesthesiology residents from the various parts of India attending two different conferences held in September–October 2018 were explained regarding the survey. Since the survey was conducted with a view to evaluate postgraduate training in trauma care, only postgraduates in training were included in the study. All faculty, private practitioners, and consultants attending the conferences were excluded from the study.
Those willing to participate in the study were given a questionnaire regarding trauma care [Table 1]. The questions were derived from the institutional trauma care support program designed by a team of specialists trained in ATLS and involved in trauma care.
|Table 1: Survey on knowledge of acute trauma care among trainee anesthesiologists (Section 1 and 2)|
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The questionnaire had three sections. The first section had questions about participants' demographic data such as age, gender, qualification, year of training, and whether studying in government or private medical college or undergoing Diploma of National Board (DNB) training.
The second section contained questions on their training as well as their perception on training in trauma care. The questions were on whether they thought trauma care training is important and helpful to their practice, whether they had formal training, whether they felt confident of handling trauma cases, whether they could triage patients, and whether they had ever been in a situation where their trauma care skills were needed.
Third section contained ten multiple-choice questions with single best response on the management of acute trauma with the emphasis on primary survey and management. These were designed to check their factual knowledge of basic trauma care. The questions were marked on a correct/incorrect basis, with a score of 1 for the correct and 0 for the incorrect answer.
The answers to questions 1–6 were considered absolutely basic knowledge to an anesthetist providing care to a trauma patient. Some training in ATLS would have made the responders score the remaining four points. If they scored 9 or 10, it was considered excellent, 7 or 8 – satisfactory, and <7 (0–6) – considered poor. The completed forms were collected and analyzed.
| Results|| |
A total of 300 forms were distributed among postgraduates attending two conferences held in September–October 2018. Postgraduates from all over the country attended these conferences, although a greater percentage was from South India. The questionnaire forms were distributed and collected under supervision at the conference to avoid contamination of information. Two hundred forms were given at one conference in September and 100 forms in October 2018. A total of 150 filled forms were returned, of which 146 forms were fully filled and could be included in the analysis. We conducted a pilot study to assess the knowledge of acute trauma care among 20 anesthesia trainees. We observed from the study that 9 (45%) of 20 trainees had satisfactory knowledge of acute trauma care. Therefore, considering 45% as the satisfactory knowledge of acute trauma care with a relative precision of 20% and a nonresponse rate of 10%, the sample size worked out to be 135. A minimum sample size of 100 is also advised by most statisticians for this type of survey, and thus, our sample size was deemed adequate.
All 146 participants were postgraduate students of anesthesia. The average (±standard deviation) age of the participants was 27.5 (±2.47) years. Of these, 74 (50.7%) were men and 72 (49.3%) were women. Majority (104%–71.2%) of the participants belonged to private medical colleges, 35 (23.97%) participants were from the government medical colleges, and 7 (4.8%) were undergoing DNB training.
There were nearly equal number of participants from the first and final year MD (53 [36.31%] and 56 [38.35%], respectively), whereas 37 (25.34%) participants were in their 2nd year of training Majority of the participants (141, 98.6%) felt that knowledge of trauma care could be useful them. Two respondents thought it was not useful in their practice, whereas three chose not comment on it. When questioned further about any deterring factors from getting the training, 105 (71.9%) delegates responded that there were no formal training sessions in trauma incorporated in the undergraduate curriculum. It was noted that 73 (50%) participants mentioned that there were not enough training centers in the country. A few participants (28; 19.2%) thought the course was expensive. Four (2.73%) of them did not believe that the training would change the outcome of the patient.
It was noted that about two-third of the respondents (68.5%) had previously been in a situation to provide trauma care. Majority (97.3%) felt the need for inclusion of trauma care in the undergraduate curriculum. One hundred and one (69.17%) participants had been in situ ations requiring them to provide trauma care. Eighty-four (57.53%) participants had dealt with trauma in the hospital, but eight (5.48%) of them were outside the hospital. Two participants had to provide trauma care at home. Two were caregivers in mass casualty, and two had to provide primary care to patients.
On enquiring, if they had actually undergone formal training in the initial trauma management, 91 (62.3%) affirmed positively to the query. Only 35 (23.97%) of them had undergone ATLS, Manipal Trauma Life Support, or similar training courses. About 62.4% were confident about their ability to provide initial trauma care, and 61% were of the opinion that they could triage trauma victims in mass casualties. About 98.63% of respondents felt that trauma life support must be included in the undergraduate curriculum. The scores obtained by the respondents were compared to the formal training or absence of it [Table 2] and [Table 3].
|Table 2: Comparison of scores obtained by the respondents who claimed to have undergone some training in trauma care with those who did not|
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|Table 3: Comparison of scores obtained by the respondents who were trained and untrained (specified training)|
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All 10 questions in the third section were on primary survey and considered basic knowledge. There were two questions on airway management, three on breathing, four on circulation, and one on disability. The percentage of correct responses to each section is given in [Table 4]. The percentage of correct responses to each question is given in [Table 5].
|Table 4: Comparison of percentage of correct responses obtained from trainee anesthesiologists to questions on primary survey|
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|Table 5: Response of the participants to each question on primary trauma care|
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| Discussion|| |
Anesthetists, by virtue of their possession of airway skills and resuscitation skills, are often called to attend to trauma victims. However, in addition to these skills, an organized and timely team approach to trauma improves the outcome., It is thus essential that anesthesia residents are formally trained in the initial management of trauma victims. This survey was conducted to assess the extent of training of an average anesthesia resident in India in the management oftrauma.
All participants were anesthesia residents with men and women in equal numbers. About 71% were from private medical colleges and 7 (4.79%) were doing DNB training. Nearly 40% were in the final year of their training. Majority opined that trauma life support is important and should be included in the curriculum. Two-thirds of the respondents claimed they had undergone training in trauma care, but only 24% could specify it. Two participants confused advanced cardiac life support training to be the same as trauma life support training.
Significant from the survey was the finding that 10% of the participants had been in situ ations where trauma care had to be provided outside the hospital. Two were at home and two were in mass casualties.
Analysis of their knowledge showed that it was far from satisfactory. There was a significant difference in the knowledge of trauma care between those who had not been trained and those who claimed to have been trained. The difference was even starker when only those who had undergone dedicated trauma care training were compared with those who had not.
There were only ten questions and all of them were on the primary survey and considered mandatory knowledge. Even among those who had undergone formal training, 53% had scored poorly. What was noteworthy was that more than 60% of the respondents felt confident in the management of trauma.
A score of 10 would be expected if they were trained formally. Only two (1.37%) delegates obtained this score. From this survey, even a score of 10 would only indicate that the responders were probably familiar with the initial trauma care management but not their practical expertise. This survey was focused on the initial trauma care management, as most anesthetists would be involved with the stabilization of the patient.
There are a number of studies emphasizing the role of ATLS. ATLS plays a crucial part in increasing the level of knowledge that helps to assess the severity of injuries, identification of management priorities, and implementation of resuscitative skills. A review article by Abu-Zidan has discussed the educational impact of trauma life support and says ATLS has brought up a marked increase in knowledge, practical skills, and crucial decision-making process in polytrauma cases. The review also stated that it is not possible to conduct randomized controlled trials to test the effect of ATLS courses on trauma mortality as all conditions cannot be standardized.
The results of our survey show that the level of training in trauma care is abysmal in our curriculum. The trainees did not seem aware of such training because they were confident in its management. Their performance did not reflect their knowledge. Organized trauma care training programs are the need of the hour in every teaching hospital in India. Monitoring the quality of training program along with periodic upgradation is also necessary. The acquired knowledge and unutilized practical skills tend to decline over time, and hence, there would be a need for recertification.
Our study has a few limitations. The practical skills of anesthesia trainees in imparting acute trauma situations were not formally assessed. Our trauma survey questionnaire was constructed on basic knowledge necessary to provide acute trauma care. It was assumed that they knew the steps if they stated so. The aim was to do a survey. Examining the participants would not have been possible as the survey was conducted at conferences where there were no facilities to conduct a simulation exercise.
One of the important points that need to be addressed is that even though the ATLS course is now available across India in several places, mainly metros, the cost of the course is prohibitively expensive. In a resource-poor country such as India, where the trauma burden is so high, it is imperative that the government as well as private establishments take the initiative to train the first responders with a much-subsidized course.
The simulation requires the use of manikins, and the commercially available ones with the replacement parts are expensive. The providers need to learn the manual skills and methodical approach. Institutions and individuals could reduce costs using indigenous materials such as rexin and foam and reduce the cost of simulation material to one-tenth of the course. Teachers across medical colleges could be trained (train the trainer) to incorporate this into postgraduate or better still undergraduate medical training programs and impart these essential skills. These could potentially save lives of hundreds and thousands of productive lives across the nation.
| Conclusion|| |
The knowledge of trauma care among trainee anesthesiologists is inadequate to provide trauma care in acute trauma scenarios. Those trainees who have undergone formal training in trauma care demonstrate better knowledge. Since training has shown to have better outcomes in preliminary patient care and outcome, such programs need to be incorporated in the regular academic program of postgraduates and undergraduates.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Peden M, McGee K, Sharma G. The Injury Chart Book: A Graphical Overview of the Global Burden of Injuries. Geneva: World Health Organization; 2002.
Joshipura MK. Total trauma care: International perspective. Hosp Today 1996;11:43-4.
Sethi AK, Tyagi A. Trauma untamed as yet. Trauma Care 2001;11:89-90.
Mock CN, Jurkovich GJ, nii-Amon-Kotei D, Arreola-Risa C, Maier RV. Trauma mortality patterns in three nations at different economic levels: Implications for global trauma system development. J Trauma 1998;44:804-12.
Joshipura MK, Shah HS, Patel PR, Divatia PA. Trauma care systems in India – An overview. Indian J Crit Care Med 2004;8:93-7. [Full text]
Carmont MR. The advanced trauma life support course: A history of its development and review of related literature. Postgrad Med J 2005;81:87-91.
Abu-Zidan FM. Advanced trauma life support training: How useful it is? World J Crit Care Med 2016;5:12-6.
Douglas RJ, Vasanthi B, Giles AJ, Kumar GA. Improving trauma care in India: A recommendation for the implementation of ATLS training for emergency department medical officers. Int J Emerg Med 2010;3:27-32.
Lo JC, Lee YH. Evaluation of an advanced trauma life support course in Taiwan. Formos J Surg 2014;47:221-6.
Ahmadi K, Sedaghat M, Safdarian M, Hashemian AM, Nezamdoust Z, Vaseie M, et al
. Effect of advanced trauma life support program on medical interns' performance in simulated trauma patient management. Chin J Traumatol 2013;16:145-8.
Ali J, Adam R, Butler AK, Chang H, Howard M, Gonsalves D, et al
. Trauma outcome improves following the advanced trauma life support program in a developing country. J Trauma 1993;34:890-8.
Ali J, Adam R, Stedman M, Howard M, Williams JI. Advanced trauma life support program increases emergency room application of trauma resuscitative procedures in a developing country. J Trauma 1994;36:391-4.
Amaraegbulam PI, Nwankwo OE. The level of knowledge of the advanced trauma life support protocol among nonspecialist doctors involved in trauma care in Enugu metropolis. Niger J Clin Pract 2013;16:67-70.
] [Full text]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]