Monday, October 27, 2014

Trauma Services in Westeros



















A perpetual state of war is the perfect environment for innovation in healthcare to flourish and nowhere is this more in need than Westeros. Currently trauma services are in disarray with pauper and king alike at risk from mismanagement in the dangerous world of the 7 kingdoms.

Alarm bells began with the peacetime death of Robert Baratheon in a hunting accident. Adequate access to quality surgical and anaesthetic care may have prevented the realm being plunged into chaos in the first place. Given his stability at presentation he had time for a full history and examination including co-morbid conditions of obesity and alcohol dependence. Expedient wound debridement and surgical control of intra-abdominal sepsis with post operative ICU care and prevention of alcohol withdrawal would have probably prevented the War of 5 Kings.

With war on 3 fronts, expert medical care was largely an afterthought with  only the Northern Army having any noticeable care for wounded soldiers. Not that this could save their king in the North from succumbing to a cross bow bolt trauma which could have been decompressed with an intercostal drain and appropriate blood products. Things got worse at the Battle of Blackwater with no recognised Burns unit in the capital leading to thousands of unnecessary deaths barely hundreds of feet from the gates to the city.

The next king to suffer from poor investment in his own healthcare system was Joffrey, appearing to die from poison setting off severe laryngeal oedema. Being in the biggest population centre in the realm would mean prompt management of a threatened airway with access to intubation and in extremis a surgical airway. None of which was forthcoming, which leads to cries of regicide.

Things are little better across the Narrow Sea in Essos where leader of the Dothraki, Khal Drogo has succumbed to wounds inflicted in a minor scuffle. Here, appropriate access to antibiotics and sepsis source control will have negated the need to use poorly defined and non evidenced based therapies used by the Blood Magi. Being Barbarians, they could be forgiven for not having a well developed trauma service, but this must become a priority given how much blood is spilt in their name. They need only look towards slavers bay for an effective surgical practice. Becoming unsullied requires an invasive procedure and the fact there are 8000 survivors is testament to go post operative care and cleanliness.

There are reasons to be optimistic, not least in the survival of the  Kingslayer after a grossly contaminated forearm amputation was promptly managed with haemorrhage and infection control from Masester Qyburn, who whilst spurned by the Maesters in their Ivory towers is producing some promising results in acute care situations, results of his treatment of the Mountain are awaited with some excitement.

So what is the answer? The Maesters and the Master of Coin need to sit down and plan an effective and wide ranging trauma network throughout the 7 kingdoms. This should start with a dedicated level 1 major trauma centre in the capital to serve the population of in excess of half a million people. This should be equipped with access to immediate radiology, general, orthopaedic, vascular and cardiothoracic surgery as well as the opening of the Oberyn Martell Memorial neurosurgery unit. This should be complemented by a hub and spoke system of trauma centres located in the major population centres of the largely rurally populated Westeros. Transportation to the MTC should be provided when patients are stable in view of the  large distances involved. Furthermore, field care should be provided by mobile trauma units following the great hosts of Westeros to war and at Tournament, with a banner befitting their neutral and altruistic nature. Lastly the Maesters need to be up to date with evidence and all must attend an ATLS course as a matter of urgency to learn how to care immediately for the injured in battle or intrigue.

Now is the perfect oppurtunity to improve trauma care in Westeros and only short sighted temporary leaders will prevent this.


1 comment:

  1. The matter is just awesome and very informative for the title and thanks for sharing this site with us.


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