Victorian Trauma Research Articles

Victorian Trauma: War, Railway Accidents, and the Vulnerable Body

Abstract: In Balaclava (1876) by Elizabeth Thompson (later known as Lady Butler) the central figure of a traumatized survivor of the Charge of the Light Brigade, modeled after real-life veteran of the Charge William Henry Pennington, was criticized as being over-dramatic. The criticism of Pennington's pose and demeanor shows the inability of the Victorian definition of "shock" to encompass what today would be termed post-traumatic stress disorder (PTSD). A shift in the Victorian model of trauma has been connected to railway travel; unrecognized has been the connection between the discourses on trauma in railway accidents and from warfare based on the vulnerability of the body. The mechanization of transport led to new anxieties about the precarity of the railway passenger's body and engendered an analogy between railway accident trauma and warfare. Surgeon Edwin Morris's A Practical Treatise on Shock After Surgical Operations and Injuries: With Especial Reference to Shock Caused by Railway Accidents (1867) made this connection explicit. Morris considered physical war wounds specific and verifiable but criticized claims against railway companies for the psychological aftereffects of accidents as unverifiable. Morris expressed the fear that both railway passengers and soldiers could simulate the effects of trauma in the absence of any physiological injury that would make their symptoms verifiable, revealing the shortcomings of the Victorian diagnosis of shock and the privileging of physical over psychological wounds.

Victorian Trauma: War, Railway Accidents, and the Vulnerable Body

Abstract: In Balaclava (1876) by Elizabeth Thompson (later known as Lady Butler) the central figure of a traumatized survivor of the Charge of the Light Brigade, modeled after real-life veteran of the Charge William Henry Pennington, was criticized as being over-dramatic. The criticism of Pennington's pose and demeanor shows the inability of the Victorian definition of "shock" to encompass what today would be termed post-traumatic stress disorder (PTSD). A shift in the Victorian model of trauma has been connected to railway travel; unrecognized has been the connection between the discourses on trauma in railway accidents and from warfare based on the vulnerability of the body. The mechanization of transport led to new anxieties about the precarity of the railway passenger's body and engendered an analogy between railway accident trauma and warfare. Surgeon Edwin Morris's A Practical Treatise on Shock After Surgical Operations and Injuries: With Especial Reference to Shock Caused by Railway Accidents (1867) made this connection explicit. Morris considered physical war wounds specific and verifiable but criticized claims against railway companies for the psychological aftereffects of accidents as unverifiable. Morris expressed the fear that both railway passengers and soldiers could simulate the effects of trauma in the absence of any physiological injury that would make their symptoms verifiable, revealing the shortcomings of the Victorian diagnosis of shock and the privileging of physical over psychological wounds.

The Association Between Fault Attribution and Work Participation After Road Traffic Injury: A Registry-Based Observational Study.

Purpose To characterise associations between fault attribution and work participation and capacity after road traffic injury. Methods People aged 15-65years, working pre-injury, without serious brain injury, who survived to 12months after road traffic injury were included from two Victorian trauma registries (n = 2942). Fault profiles from linked compensation claims were defined as no other at fault, another at fault, denied another at fault, claimed another at fault, and unknown. Claimant reports in the denied and claimed another at fault groups contradicted police reports. Patients reported work capacity (Glasgow outcome scale-extended) and return to work (RTW) at 6, 12 and 24 months post-injury (early and sustained RTW, delayed RTW (≥ 12 months), failed RTW attempts, no RTW attempts). Analyses adjusted for demographic, clinical and injury covariates. Results The risk of not returning to work was higher if another was at fault [adjusted relative risk ratio (aRRR) = 1.67, 95% confidence interval (CI) 1.29, 2.17] or was claimed to be at fault (aRRR = 1.58, 95% CI 1.04, 2.41), and lower for those who denied that another was at fault (aRRR = 0.51, 95% CI 0.29, 0.91), compared to cases with no other at fault. Similarly, people had higher odds of work capacity limitations if another was at fault (12m: AOR = 1.49, 95% CI 1.24, 1.80; 24m: 1.63, 95% CI 1.35, 1.97) or was claimed to be at fault (12m: AOR = 1.54, 95% CI 1.16, 2.05; 24m: AOR = 1.80, 95% CI 1.34, 2.41), and lower odds if they denied another was at fault (6m: AOR = 0.67, 95% CI 0.48, 0.95), compared to cases with no other at fault. Conclusion Targeted interventions are needed to support work participation in people at risk of poor RTW post-injury. While interventions targeting fault and justice-related attributions are currently lacking, these may be beneficial for people who believe that another caused their injury.

Trends in the Nature and Management of Serious Abdominal Trauma.

There have been recommendations for increased non-operative management (NOM) of abdominal trauma in adults. To assess the impact of this trend and changes in the epidemiology of trauma, we examined the management of serious abdominal injuries and mortality, in Victorian major trauma patients 16years or older, between 2007 and 2016. Using data from the population-based Victorian Trauma Registry, characteristics of patients who underwent laparotomy, embolisation, laparotomy and embolisation, or NOM, were compared with the Chi-square test. Poisson regression was used to determine whether the incidence of serious abdominal injury changed over time. Temporal trends in the management of abdominal injury and in-hospital mortality were analysed using, respectively, the Chi-square test for trend, and multivariable logistic regression. Of 2385 patients with serious abdominal injuries, 69% (n = 1649) had an intervention; predominantly a laparotomy (n = 1166). The proportion undergoing laparotomy decreased from 60% in 2007 to 44% in 2016 (p < 0.001), whilst embolisation increased from 6 to 20% (p < 0.001). Population-adjusted incidence of abdominal injury increased 1.6% per year (IRR 1.016, 95% CI 1.002-1.031; p < 0.024), predominantly in people aged 65years and over (4.6% per year). Adjusted odds of in-hospital mortality declined 6.0% per year (adjusted odds ratio 0.94; 95% CI 0.89, 1.00; p = 0.04). Whilst the incidence of major abdominal trauma increased during the study period, there was a reduction in the proportion of patients managed with laparotomy and reduction in the adjusted odds of in-hospital mortality. Older patients, for whom management is influenced by the complex interplay of frailty and co-morbidities, had lower laparotomy rates.

Yield of serious axial injury from pan scans after blunt trauma in haemodynamically stable low-risk trauma patients.

Whole body computed tomography (WBCT) scanning for trauma has gained popularity but its role in low-risk patients is controversial. We aimed to determine the rate of serious axial/truncal injury and emergency intervention in conscious, stable patients undergoing WBCT for blunt trauma in two non-trauma centre EDs in the Victorian trauma system. Retrospective cohort study by medical record and radiology report review. Patients were included if they were conscious, haemodynamically stable adults presenting by ambulance and having WBCT scan. Exclusion criteria were age <16 years, no history of trauma, Glasgow Coma Scale <14, systolic blood pressure <90 mmHg and intoxication with alcohol or drugs. Data collected included demographics, clinical findings, results of CT scans and emergency interventions (emergency truncal surgery, transfer to a trauma centre and/or transfusion within 24 h). The outcomes of interest were the rate of defined serious axial/truncal injury and emergency interventions. One hundred and four patients were studied. Median age was 45 years; 67% were men. Median injury severity score (ISS) was 1.5 (interquartile range 0-5); only one patient had an ISS ≥15. Ninety (87%, 78-92%) patients had no defined serious injury. Five (5%) patients had a defined emergency intervention - four trauma centre transfers and one transfusion. Two of these were not trauma-related. The rate of serious axial/truncal injury was low. The high rate of normal scans makes it likely that the risk:benefit ratio between injury identification and radiation related cancer risk is unacceptably high. This data supports a selective CT strategy in low-risk trauma patients.

Advancing age and trauma: Triage destination compliance and mortality in Victoria, Australia

ObjectiveTo describe the association between increasing age, pre-hospital triage destination compliance, and patient outcomes for adult trauma patients. MethodsA retrospective data review was conducted of adult trauma patients attended by Ambulance Victoria (AV) between 2007 and 2011. AV pre-hospital data was matched to Victorian State Trauma Registry (VSTR) hospital data. Inclusion criteria were adult patients sustaining a traumatic mechanism of injury. Patients sustaining secondary traumatic injuries from non-traumatic causes were excluded. The primary outcomes were destination compliance and in-hospital mortality. These outcomes were evaluated using multivariable logistic regression. ResultsThere were 326,035 adult trauma patients from 2007 to 2011, and 18.7% met the AV pre-hospital trauma triage criteria. The VSTR classified 7461 patients as confirmed major trauma (40.9%>55 years). Whilst the trauma triage criteria have high sensitivity (95.8%) and a low under-triage rate (4.2%), the adjusted odds of destination compliance for older trauma patients were between 23.7% and 41.4% lower compared to younger patients. The odds of death increased 8% for each year above age 55 years (OR: 1.08; 95% CI: 1.07, 1.09). ConclusionsDespite effective pre-hospital trauma triage criteria, older trauma patients are less likely to be transported to a major trauma service and have poorer outcomes than younger adult trauma patients. It is likely that the benefit of access to definitive trauma care may vary across age groups according to trauma cause, patient history, comorbidities and expected patient outcome. Further research is required to explore how the Victorian trauma system can be optimised to meet the needs of a rapidly ageing population.

The Spectral Presence of the Franklin Expedition in Contemporary Fiction

This essay highlights the spectral analogies between the attempts to discover the fate of Sir John Franklin's Arctic expedition in the 1850s, and the sudden eruption of novels in the 1990s dealing with its demise. In both cases, supernatural tropes occupied a central role in how Western audiences confronted Arctic disaster. A thematic survey focusing on two novels demonstrates how contemporary mappings of Arctic exploration utilize spectral motifs in reconstructing Victorian trauma.

Victorian trauma outcomes—Are we getting better?

Victorian trauma outcomes—Are we getting better?

Addressing inadequacies in Victoria's trauma system: Responses of the Consultative Committee on Road Traffic Fatalities and Victorian trauma services

Victoria's new trauma care system has been followed by reductions in preventable and potentially preventable deaths and in deficiencies contributing to death. This improvement has followed triaging more patients to expanded major trauma services where mortality was already lower rather than to improved results within the major trauma services, metropolitan or rural trauma services or ambulance services, Victoria. The objective of the present study was to identify continuing inadequacies within the individual trauma services and in association with representatives of these services to develop appropriate countermeasures. Initially, presentations were made to each trauma service of their fatalities evaluated after introduction of the new trauma system. At separate working party meetings with each service consensus recommendations were finalized and these disseminated to stakeholders. Recommendations related to the need for Trauma Director/Coordinator appointments at all designated hospitals receiving major trauma, improved facilities and equipment, the trauma team, referral, communications, protocols, a prompting system, education, audit and feedback, infrastructure, staffing, documentation and inter-hospital patient transfer. Interaction between the Consultative Committee on Road Traffic Fatalities and Victorian trauma services identified continuing deficiencies in the new trauma care system and developed consensus recommendations to target these problems. These require implementation through the State Trauma Committee.

Aortic transection: demographics, treatment and outcomes in Victoria, Australia

ObjectiveThe epidemiology of aortic transection is changing with improvements in road safety and the use of endovascular stents. This research investigates the profile of cases and outcomes of traumatic thoracic...

Book Reviews

Books reviewed in this issue. Shaking Hands on the Fringe: Negotiating the Aboriginal World at King George's Sound. By Tiffany Shellam The French Explorers and Sydney 1788–1831. By Colin Dyer Servants Depots in Colonial South Australia. By Marie Steiner Australia Though Women's Eyes. By Ann Standish Showtime: A History of the Brisbane Exhibition. By Joanne Scott and Ross Laurie Gallipoli. The End of the Myth. By Robin Prior Shattered Anzacs: Living with the Scars of War. By Marina Larsson Destination Australia: Migration to Australia since 1901. By Eric Richards Divine Discontent: The Brotherhood of St Laurence: A History. By Colin Holden and Richard Trembath Political Tourists: Travellers from Australia to the Soviet Union in the 1920s–1940s. Edited by Sheila Fitzpatrick and Carolyn Rasmussen Father of the House: The Memoirs of Kim E. Beazley. By Kim E. Beazley, with annotations by Kim C. Beazley and John Bond Voices from the Ships: Australia's Seafarers and their Union. By Diane Kirkby Global Citizens: Australian Activists for Change. Edited by Geoffrey Stokes, Roderic Pitty and Gary Smith The State Of Industrial Relations. Edited by Christopher Sheil. Australian Social Attitudes 2: Citizenship, Work and Aspirations. Edited by David Denemark, Gabrielle Meagher, Shaun Wilson, Mark Western and Timothy Phillips The Collectors of Lost Souls. Turning Kuru Scientists into Whitemen. By Warwick Anderson Britain and the West New Guinea Dispute, 1949–1962. By Nicholas Tarling War of No Pity: The Indian Mutiny and Victorian Trauma. By Christopher Herbert Making History Now and Then: Discoveries, Controversies and Explorations. By David Cannadine Churchill: the Greatest Briton Unmasked. By Nigel Knight Liberal Imperialism in Germany. Expansionism and Nationalism 1848–1884. By Matthew P. Fitzpatrick The Oxford Handbook of Fascism. Edited by R.J.B. Bosworth The Hemingses of Monticello: an American Family. By Annette Gordon‐Reed The Malays. By Anthony Milner The Coldest Winter: America and the Korean War. By David Halberstam Tours of Vietnam: War, Travel Guides, and Memory. By Scott Laderman The Power of Words in International Relations: Birth of an Anti‐Whaling Discourse. By Charlotte Epstein Charles Darwin on the Origin of Species: The Illustrated Edition. Edited by David Quammen Darwin Loves You: Natural Selection and the Re‐enchantment of the World. By George Levine

Management of blunt bowel and mesenteric injuries: Experience at the Alfred hospital.

The incidence of blunt bowel and mesenteric injury (BBMI) has increased recently in blunt abdominal trauma, possibly due to an increasing number of high-speed motor accidents and the use of seat belts. Our aim was to identify the factors determining the time of surgical intervention and how they affect the outcome of the patient with BBMI. This was achieved by reviewing our experience as a major Victorian trauma service in the management of bowel and mesenteric injuries and comparing this to the experiences reported in the literature. A retrospective study reviewing 278 consecutive patients who presented to the Alfred trauma center with blunt bowel and mesenteric injuries over a 6-year period. The patient cohort comprised 278 patients with BBMI (66% were male, 34% were female), of whom 80% underwent a laparotomy, 17% were treated conservatively and 3% were diagnosed post-mortem. In terms of time from admission to laparotomy, 67% were treated within 0-4 h, 9% within 4-8 h, 3% within 8-12 h, 10% within 12-24 h, 4% within 24-48 h and 7% at >48 h. A focused abdominal sonography for trauma (FAST) was performed in 86 patients, of whom 51% had a positive FAST, 44% had a negative FAST and 4% had an equivocal FAST. Overall, 13% of the patient cohort did not have a FAST. Computerized tomography (CT) scans were undertaken preoperatively in 68% of the patients, revealing free gas (22% of patients), bowel-wall thickening (31%), fat and mesenteric stranding or hematoma (38%) and free fluid with no solid organ injury (43%). The timing of surgical intervention in cases of BBMI is mostly determined by the clinical examination and the results of the helical CT scan findings. The FAST lacks sensitivity and specificity for identifying bowel and mesenteric trauma. A delayed diagnosis of > 48 h has a significantly higher bowelrelated morbidity but not mortality.

The Victorian trauma system—Looking into the future

The Victorian trauma system—Looking into the future

Anti-Post (In This Case) Colonial

War of No Pity: The Indian Mutiny and Victorian Trauma by Christopher Herbert. Princeton, NJ: Princeton University Press, 2007. Pp. 334. $35.00 cloth. The First War of Independence, the Sepoy Rebellion, the Indian Mu tiny: the lack of consensus about what to call the uprising that began as a mutiny of sepoys—South Asian soldiers in the East India Compa ny's army—in 1857 suggests the on going conflict over a battle the causes and consequences of which remain fraught in several national imaginations. This war spread be yond the soldiers with whom it be gan to the civilian population and took more than a year to fully sup press. Christopher Herbert's War of No Pity: The Indian Mutiny and Vic torian Trauma is only partially about this conflict. It seems to want to

War of no pity: the Indian Mutiny and Victorian trauma

List of Illustrations xi Acknowledgments xiii INTRODUCTION: Jingoism, Warmongering, Racism 1 CHAPTER ONE: Diabolical Possession and the National Conscience 19 CHAPTER TWO: Three Parables of Violence 58 CHAPTER THREE: The Culture of Retribution: Capital Punishment, Maurice Dering, Flotsam 99 CHAPTER FOUR: The Mutiny in Victorian Historiography 134 CHAPTER FIVE: The Infernal Kingdom of A Tale of Two Cities 205 CHAPTER SIX: Lady Audley's Secret: The Mutiny, the Gothic, and the Feminine 239 EPILOGUE: Fiction Fair and Foul: Novels of the Mutiny 273 Notes 289 Works Cited 307 Index 317

War of No Pity: The Indian Mutiny and Victorian Trauma, by Christopher Herbert

<i>War of No Pity: The Indian Mutiny and Victorian Trauma</i>, by Christopher Herbert

BOOKS IN SUMMARY

Book reviewed in this issue:Nation and History: Polish Historians from the Enlightenment to the Second World War. Edited by Peter Brock, John D. Stanley, and Piotr J. Wróbel.War of No Pity: The Indian Mutiny and Victorian Trauma. by Christopher Herbert.Medieval History Writing and Crusading Ideology. Edited by Tuomas M. S. Lehtonen and Kurt Villads Jensen with Janne Malkki and Katja Ritari.Vitalizing Nature in the Enlightenment. by Peter Hanns Reill.History and Nation. Edited by Julia Rudolph.Women's History in Global Perspective, Volumes 1–3. Edited by Bonnie G. Smith.Haunted by Empire: Geographies of Intimacy in North American History. Edited by Ann Laura Stoler.Writing Early Modern History. Edited by Garthine Walker.

Management Deficiencies and Death Preventability of Road Traffic Fatalities Before and After a New Trauma Care System in Victoria, Australia

The Consultative Committee's findings that preventable or potentially preventable (P/PP) death rates (survival prospects > or =25%) of road crash fatalities who received treatment were unaltered between 1992 and 1998 led to a Ministerial Taskforce on Trauma and the gradual introduction of a new Victorian trauma care system. The present study compares outcomes before (1997-1998) and after (2002-2004) the new system. The emergency and clinical management and death preventability of 245 consecutive fatalities in the 'before' period and 193 in the 'after' period was assessed by the committee's multidisciplinary panels using the complete hospital, ambulance, and autopsy findings. Emergency department admissions to expanded Major Trauma Services (MTS) increased from 34% to 62% (p < 0.05). More patients were attended by Advanced Trauma Life Support paramedics (p < 0.05) and scene times increased (p < 0.05). Patients admitted within 1 hour decreased from 70% to 45% (p < 0.05). The mean number of deficiencies per patient including those contributing to death was decreased (p < 0.05). The combined P/PP death rates decreased from 36% to 28% (22% relative risk reduction). The P/PP death rates for MTS, Metropolitan Trauma Services, Rural Trauma Services, and Urgent Care Centers for 2002 to 2004 were 25%, 33%, 50%, and 83%, respectively, and did not differ significantly from those of 1997 to 1998 (23%, 49%, 36%, 75%, respectively). The P/PP death rates in MTS were less than those of the other hospital groups. The new Victorian trauma care system has resulted in a significant decrease in deficiencies including those contributing to death and a decrease in P/PP deaths rates. The improvement has been largely consequent to a marked increase in admissions to MTS.

An Interview with Terry Marshall - Recipient of the 2007 National Institute of Clinical Studies and Victorian Trauma Foundation Fellowship

Terry Marshall, a Clinical Support Officer at Melbourne’s Metropolitan Ambulance Service in Australia, was one of six recipients in to receive a prestigious Fellowship co-sponsored by the Victorian Trauma Foundation (VTF) and the National Institute of Clinical Studies (NICS). The award will enable Terry to undertake research in the area of paramedic assessment and management of acute pain, as he explains in the following interview with JEPHC.