Region-Specific Epidemiology

Australia and New Zealand have a combined population of approximately 27 million people (approximately the population of Texas) spread over a very large land mass of nearly 8 million square kilometers (roughly the size of the continental United States). In Australia and New Zealand, ownership and use of firearms and, in particular, handguns are limited by strict laws. With large farming areas in both countries, firearms are present but at a much lower per capita rate than in the United States (22.6 guns per 100 people in New Zealand; 15 guns per 100 people in Australia; 88.8 guns per 100 people in the United States). Additionally, the incidence of a mass shooting events in Australia and New Zealand has been very low to nonexistent, with only one major event in each country in the last 20 years.

As in most countries, despite being illegal, the carrying of knives is harder to police. Among most cultural groups in Australia and New Zealand, interpersonal violence most commonly involves blunt mechanisms rather than stabbings or shootings. As a result the vast majority (over 90%) of trauma in both Australia and New Zealand is of a blunt mechanism with penetrating mechanisms being the cause in less than 10% of trauma patients. Most vascular trauma that occurs in the community is therefore to lower extremity vessels in association with fractures and dislocations ( Fig. 25-1 ), to the thoracic aorta in association with deceleration injury ( Fig. 25-2 ), and to the cervical vessels in association with blunt trauma ( Fig. 25-3 ). Penetrating trauma occurs with the usual distribution of injury from accidental injuries such as arms lacerated when placed though windows and less commonly from interpersonal violence with firearms. Given the increasing rate of endovascular procedures performed by a range of providers and in areas such including those in intensive care units (ICUs), a significant proportion of penetrating vascular trauma in Australia and New Zealand arises from iatrogenic mechanisms (e.g., damage to the femoral, the subclavian, and the carotid vessels).

Dislocated knee associated with distal ischemia.

Computed tomography (CT) showing blunt thoracic aortic rupture.

Common carotid traumatic dissection secondary to blunt trauma.

Although there are no longstanding national trauma registries, there are a number of well-established institutional registries including the Auckland City Hospital Trauma Registry established in 1994, and cumulative reports indicate an incidence of vascular injury comprising approximately 1.5% of trauma admissions. In this extensive trauma experience, roughly 75% of vascular injuries have occurred due to blunt mechanisms and 25% from penetrating mechanisms. Over the past three decades, there have been no major changes in the etiology of vascular trauma, although the absolute numbers have increased gradually in line with population growth.

Region-Specific Systems of Care

There is considerable variation in the systems of care under which trauma care is provided in Australia and New Zealand. In general, it is not well systematized, although the state of Victoria in Australia has run an effective statewide trauma system for over a decade and has been able to demonstrate both a significant reduction in mortality and an improved functional outcome for survivors. The American College of Surgeons (ACS) verification system has been adopted by the Royal Australasian College of Surgeons (RACS), and some hospitals and regions have embraced this process improvement strategy in systems for the delivery of care. In general, however, trauma care is provided by a range of hospitals whose size and capability varies widely. In the large metropolitan centers of Australia and New Zealand, there exist hospitals that match to a greater or lesser degree the trauma care capabilities of an ACS Level I trauma center. In the regional and provincial areas, base hospitals usually have the capabilities of an ACS Level II center. In more rural and remote areas, trauma capabilities are limited. In the rural areas, most trauma patients are taken to the nearest regional hospital, which is the only real option. In the cities and urban areas, there is usually some form of geographic boundary used to define the receiving medical center. Only in Victoria has a really effective destination policy been developed that is highly efficient in ensuring major trauma patients are taken to one of only two adult or one pediatric (Level I) centers.

Surgical Training and Certification

The RACS is the only training oversight body for surgeons in Australia and New Zealand, and the college trains in nine surgical disciplines including vascular surgery. Prior to 1997, vascular surgery was integral to general surgical training with further expertise being available in post-fellowship positions, but lately there has been a separate training program that has graduated about 10 vascular surgeons per year. There is no separate training program in trauma surgery; and additional expertise in this area, beyond what might be obtained in general, orthopedic, neurosurgical, or vascular surgical training is only available in post-fellowship programs either within Australia and New Zealand or overseas. Thus it is possible to be deemed by the registering authorities as a certified general surgeon or a certified vascular surgeon, but not a certified trauma surgeon as this specialty is not one of the nine recognized by the regulatory entities. Overall, in New Zealand and Australia there is approximately 1 surgeon for every 6000 people. However, with respect to the specific specialties likely to manage vascular trauma, there is 1 general surgeon for every 16,000 persons and 1 vascular surgeon for every 145,000 (RACS surgical workforce projections 2025).