Major trauma: Are women receiving the same response?

Any injury that could result in death or disability can be classified as major trauma. Whilst this is often depicted as young males in collisions or assaults, it also and more frequently includes older people, often women with falls and low impact injuries. However, these cases are easily overlooked despite the potential for life changing repercussions.

In my dissertation at the University of Southampton, I explored whether women and men are equally identified as major trauma and consequently triaged appropriately and the difference I found was striking. My study compared male vs female identification as major trauma, prior to hospital admission, as well as exploring how frequently they received a trauma team response on arrival to hospital. In this retrospective, observational study I found that the tool used to detect major trauma prior to hospital admission is equally sensitive in both men and women, but despite this, women were less likely to receive a trauma team. Among 425 patients with major trauma, just under a quarter of women received a specialist trauma team response on arrival at hospital, compared with just over half of men.

Understanding that difference means looking beyond the familiar picture of a young man injured in a collision or assault. It also means being cautious about what the findings can tell us.

Before analysing the patient records, I reviewed research into sex and gender differences in healthcare. A recurring concern was the limited representation of women in research, including trauma research, and the consequences of using male physiology as the basis for care.

Men and women can sustain different injuries in similar circumstances and respond differently after injury. Social expectations can also influence behaviour, how injuries happen and how patients are perceived by healthcare staff. Biological and social factors may therefore combine to affect the care people receive.

One study I discussed in my dissertation examined tranexamic acid, a medicine used to reduce heavy bleeding following trauma. Although it is equally effective in both sexes, it was given more frequently to men than women with comparable injury severity and similar causes of injury, apart from motor vehicle crashes. That made me wonder whether differences might also exist in trauma triage.

The records available for my evaluation identified patients by sex rather than gender identity. This allowed me to compare patients recorded as female and male, although the data could not adequately reflect the experiences of people whose gender differed from their recorded sex.

I anonymised records from the Trauma Audit and Research Network for patients seen at University Hospital Southampton between January 2021 and January 2022. The evaluation included 159 women and 266 men. Children under 16 and patients transferred from other hospitals were excluded.

Every patient had an Injury Severity Score above 15, the threshold used in this evaluation to identify major trauma. This score is retrospective; it assesses the extent of a person’s injuries once they have been identified, but is not reflective of how acutely unwell someone was when they first arrived at hospital.

The average age was approximately 63, and almost 59% of the patients were over 60. Women were older on average than men, more often had injuries caused by less forceful events and generally had lower injury severity scores.

These differences needed careful consideration. Otherwise, it would have been easy to attribute a difference in care to sex when age or the nature of the injury might help to explain it.

Of the 159 women, 36 received a specialist trauma team response. Among the 266 men, 139 received that response. That is approximately 23% of women compared with 52% of men, a statistically significant difference.

The same pattern appeared in both younger and older patients. Among those under 65, around 29% of women received a trauma team response, compared with 57% of men. In the over-65 group, the figures were 17% and 48%.

The difference persisted in the analyses examining age, injury severity and how the injury happened. Women had lower odds of receiving a trauma team response across the categories examined, with one exception: Injuries caused by blows without weapons. There was only one woman in that group, so it could not support a reliable finding in the opposite direction.

The bypass tool results looked more similar. Where a result was recorded, approximately 72% of women and 75% of men were positive, indicating that they should be taken to a major trauma centre. There was no statistically significant difference between the sexes in those recorded results.

There was a substantial gap in the bypass information. Results were missing for approximately 76% of women and 50% of men. The similarity among the recorded results therefore cannot establish that the tool performed equally across the whole group.

There may have been practical reasons for the missing information. If Southampton was already the nearest hospital, ambulance clinicians might not have needed the bypass tool to choose a destination. Alternatively, they might not have used it because major trauma was not suspected. The evaluation could not establish why the results were missing, including why this happened more often for women.

The records also lacked individual clinical observations and details of each patient’s injuries. I could not compare how acutely unwell women and men were on arrival or determine whether the response was appropriate in every case. Nor did the evaluation establish whether differences in trauma team activation affected recovery or survival.

This was a study of 425 patients in one trauma network during a particular period. It cannot describe current practice or establish what happens elsewhere. The data were entered manually, and I acknowledged in my dissertation that the statistical analysis should be checked by statisticians. It is also important to note that this study was purely observational, prompting a need for further prospective research.

Several factors might help to explain the difference in trauma team responses. Traditional trauma education has focused on younger patients injured in high-speed collisions, falls from height, shootings or stabbings. Older people injured in less forceful events may be less readily recognised as needing a specialist response. Women made up a greater proportion of this latter group in my evaluation.

Conscious or unconscious gender bias may also play a part. An impression formed before a patient reaches hospital could influence the receiving team’s assessment. These are possibilities raised by the findings and the literature I reviewed. My study did not demonstrate that bias caused the disparity.

Larger evaluations across other trauma networks would help to establish whether the pattern is repeated. Better recording of bypass decisions would make the picture clearer. Conversations with ambulance, helicopter emergency and hospital teams could also explore how they recognise major trauma and whether assumptions about sex or gender influence their decisions.

For everyone supporting people after serious injury, this question begins well before rehabilitation. It begins when someone first assesses what has happened and decides which team is needed. An older woman injured in a fall may not fit the traditional picture of major trauma. We need further research to understand whether that makes it harder for her to receive the specialist response she needs.