The Aachen Trauma Experience
By Philip McCann
Background
In July 2011 I had the opportunity to travel to Aachen University Hospital in northwest Germany for a two week OOPE. This 1356 bed unit acts as a regional level 1 trauma centre serving a population of approximately 500,00. The area also has four smaller hospitals which co-operate in a “take” system, alternating basic admissions on a daily basis, with Aachen accepting general admissions on Tuesdays and Fridays. However all polytrauma comes directly to Aachen.
The unit is run in a hierarchical model, with Professor HC Pape leading the department. He pioneered much of the early work into Damage Control Orthopaedics, the systemic effects of reaming in intrameduallary nailing and pelvic ring reconstruction. Under his direction, there are a body of consultants, each of differing levels of experience and with their own sub-specialist interest. Professor Pape assumed ultimate responsibility of all trauma patients, regardless of who they were admitted under.
The training system is similar to the American model, with early specialisation directly following medical school. No deanery model exists and candidates apply direct to the hospital, where they spend the majority of their training, rotating to work under different consultants within the department. Pure trauma practice, elective orthopaedics is a separate training programme and sub-speciality.
Activities for junior staff alternates between theatres, clinic and ward cover. On-call duties include covering all ward work (without a house officer) in addition to managing the admissions. The call runs for 24 hours with the following day off, on a 1:6 basis. EWTD was not applied. No operations were performed out of hours independently by trainees. A consultant must be present before the patient can be anaesthetised. Consultants also work 1:6.
The Daily Routine:
0715 ITU/HDU: Multi-disciplinary ward round with the intensive care physicians on every patient under the trauma team. Many patients are under shared care with the general surgeons and neurosurgeons, for the management of complex multi-system trauma. I understood that this system was introduced by Professor Pape, after his experience working in North America. I found this the various teams interacted well with each other.
0745 X-Ray Meeting - All admissions and referrals are discussed and each fluoroscopic image taken in theatre in the last 24 hours was critiqued by the Professor and other senior consultants.
0815 Theatres/Clinic - Three trauma theatres to visit. All cases throughout the entire theatre complex (33 suites) displayed on a real time programme on the hospital intranet. The patients were asleep on the table on arrival. No anaesthetic or recovery rooms so long delays between cases. Time used to return to office to complete administrative tasks.
One theatre mainly dealt with spinal trauma, whilst the other two for general limb trauma. No laminar flow.
Fracture clinic also ran in the morning session. Staffed by a consultant and two trainees. Approximately 20-30 patients.
1600 X-Ray Meeting - Update on the admissions that day and in depth review of current inpatients. Juniors asked to present cases and justify management plans. Often accompanied by brief ward round with team reviewing outstanding issues and checking patient suitability for the following days list.
1800 Finish
Travel Arrangements & Accommodation
I flew from Heathrow to Cologne, and from there took a direct train (approximately one hour) to Aachen. I had the opportunity to stay with one of the consultants working in the Trauma unit, Dr Richard Sellei. He very kindly put me up for the duration of the visit, and also acted as my guide both in and out of the hospital.
Summary
My experience in Germany was extremely interesting. It was a privilege to witness how a modern European Level 1 Trauma Centre operates. Generally speaking, the management of most injuries was very aggressive, following AO principles with most fractures treated operatively. I encountered surprisingly little circular frame work, with open reduction and internal fixation the treatment of choice for many fracture patterns (after emergent spanning monolateral external fixation if required).
Operatively, it was not as intense as I expected, with 2-3 cases performed per theatre per day. The admissions ranged from 5-15 per day. However, the staff were very knowledgeable about every aspect of trauma, which enabled me to explore some of my questions regarding specific injuries and management algorithms.
The hospital also has both a biomechanical and cadaveric laboratory, so I had the opportunity to attend a teaching session for the trainees on pelvic fracture management, placing external fixators and practising surgical approaches. The department has an enthusiastic research ethos, so there is the option to get involved with a project or two if you wish.
Overall, I would definitely recommend visiting Aachen to any trainee who wants to incorporate a significant trauma practice into their future job plan.
