Surgical News spoke with trauma care pioneer and former RACS president Professor Ian Civil

Professor Ian Civil, a pioneer of trauma care in Aotearoa New Zealand (AoNZ) and former RACS president, ends his time at the helm of the Major Trauma National Clinical Network (MTNCN) (now the National Trauma Network [NTN]). Beginning his career in the 1980s, he is credited with spearheading staggering improvements in the treatment of severe trauma in AoNZ and internationally

According to the 2021-22 National Trauma Network Annual Report, the rate of death following major trauma in AoNZ is 7.4 per cent. That’s half the case fatality rate of 2012, when the network first began, and is not far above the six per cent target that would bring it into line with international best performers such as Alberta in Canada and Victoria in Australia.

Improvements like these would be enviable for many fields of medicine but trauma is a relatively new subspecialty, especially in AoNZ. As such, trauma care has had some catching up to do. 

The marked uptick in patient outcomes is partly due to new techniques and technology, as well as advances in the philosophy and understanding that underpins the treatment of trauma.

In AoNZ, it can also be attributed to the passion and dedication of one man—Professor Civil.

Through his work as a surgeon, and his research, involvement in education and training, and ability to join people together and create connection, Professor Civil has made a significant contribution to the knowledge around trauma care. He has helped the spread and adoption of best practice among trauma professionals across AoNZ and the world.

For someone who has made such a mark in his subspecialty, you would imagine his career had been planned out from the get go. In fact, Professor Civil says he doesn’t really know why he chose the field of trauma.

As a senior registrar, in 1984, he got involved in a major piece of trauma research and after that he was hooked. With his General Surgery training complete, he headed to the US. Back then however, there weren’t a lot of opportunities for prospective trauma surgeons. Professor Civil took up a Fellowship in Vascular Surgery in Cleveland instead.

Eventually, he did land a place as a trauma Fellow, in large part thanks to a reference from his good friend—also a former RACS president—Dr Anne Kolbe.

At that time, the generalist was the most respected type of surgeon. Professor Civil, on the other hand, had trained in two sub-specialties (it was only in 1995 that Vascular Surgery became a specialty in its own right) and securing a job back in AoNZ was proving difficult.

Working his connections again, he carved out an unusual path for himself. Before moving to the US, Professor Civil  was in the New Zealand Army’s Reserve Force (formerly the Territorial Force). In 1987, the Army took him on as a military surgeon.

While this could have been professionally limiting, Professor Civil said it gave him freedom and he volunteered his surgical services. He became an honorary surgeon at the Auckland Hospital and AoNZ’s first and only senior lecturer in trauma and military surgery at the University of Auckland School of Medicine.

He remained on active duty with the Army until 1993 during which time he completed exercises in the Soloman Islands and led the NZ Army medical team to the first Gulf War.

By the time he left the army, Professor Civil had secured a permanent position at Auckland Hospital. He ascended to the role of Director of the hospital’s Trauma Services in 1994.

His involvement in international trauma organisations is extensive. He was president of the Association for the Advancement of Automotive Medicine (AAAM) in 1999 and of the International Association for the Surgery of Trauma and Intensive Care (IATSIC) from 2007 to 2009. Professor Civil is a founding member of the Australasian Trauma Society and served as president from 2011 to 2013. He was also Clinical Lead of Safe Surgery New Zealand, an expert advisory group for Health Quality and Safety Commission (HQSC), which was disbanded in 2021.

Within RACS, Professor Civil was a councillor from 2003 to 2012 and from 2010 to 2012 served as president. His nine-year stint on Council saw him cross the Tasman 77 times. He was also Censor-in-Chief and Chair of the Board of Basic Surgical Training.

One of his contributions to trauma care was to bring a level of professionalism and consistency to its practice in AoNZ. As the first Australasian to complete an Early Management of Severe Trauma (EMST) course, in the US, he saw the benefits of bringing the training to his colleagues at home.

RACS has been delivering the course now since 1988 and Professor Civil has been an instructor from the beginning (not to mention his six-year stint as chair of the EMST Committee). He said it has become the “single thread” that runs through all of trauma care. The course is mandated for all surgical specialties and encouraged for others involved in trauma care, from anaesthetists to rural GPs. Nurses are involved as observers.

In 2012 Professor Civil was appointed National Clinical Lead for the MTNCN for the Ministry of Health and the Accident Compensation Corporation (ACC). The purpose of the new body was to improve patient outcomes across the board and reducing the variation that meant patient outcomes were better in some regions than others.

It has been a success and has gained international recognition and respect.

Professor Civil puts that down to an organisational model that put decision-making and budgetary control in the hands of clinicians, not bureaucrats or politicians.

One of the decisions that has helped shift the dial on trauma care included the implementation of destination policies, which mean patients are sent to the best hospital for their needs even if other hospitals are closer. Appropriate early care has proven central to improved outcomes.

Another initiative the trauma network put in place was a trauma registry. While not having a direct impact on patient outcomes, the registry makes it possible to quantify the state of trauma care in AoNZ, undertake quality improvement activities, and allows progress to be measured and regions to be compared.

The secret sauce in all of this, and what made the MTNCN so effective according to Professor Civil, was “collective enthusiasm and personal connections”.

I would be in every hospital in the country at some stage every year and that generated connection. That’s important if you want improvements.”

It is this connection that encourages trauma nurses to keep the trauma registry up to date and to make clinicians more comfortable transferring cases to other hospitals where appropriate. It’s also what filled a Wellington conference venue in 2023 when Professor Civil independently organised the National Trauma Symposium.

And it is what Professor Civil fears will be lost as the trauma network begins to move in a new direction. With the establishment of a centralised public health body, Te Whatu Ora – Health New Zealand, the decision has been made to reorganise the networ.

Professor Civil, who exited the National Trauma Network (what was the MTNCN) in late 2023, fears the new structure will be less agile and make it harder for clinicians to input into decision-making. He also worries the enthusiasm for the work of the network will “peter out”.

While Professor Civil may no longer be involved with the trauma network, he continues to be a leading force within AoNZ trauma services. He continues to lead Auckland Hospital’s Trauma Services and is Professor of Surgery at the University of Auckland.

With half of major trauma sources in AoNZ coming from traffic crashes (involving everything from cars and motorbikes to e-scooters and pedestrians), 30 per cent from falls, 15 per cent from interpersonal violence and five per cent from burns, the work of a trauma surgeon can take a toll.

Professor Civil said it’s the patients who are young and those that get unlucky—who are injured through no fault of their own—that have the most effect on him on a personal level.

“When they die, and you have an inability to do better for them—those are the ones that stay with you.”