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Magazine
Challenges in trauma care
DR. J.P. SELVAKUMAR
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There is a need for a structured system to handle trauma from accidents, the third largest killer in India.
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Trauma is described as a morbid condition of body caused by wound or external violence.
Dr. Westaby
Few events are more distressing than an unexpected loss of life or permanent disability caused by physical violence or accidental injury. Particularly tragic is the injured, potentially salvageable patient who dies needlessly through delay in retriev
al, inadequate assessment or ineffective treatment.
Trauma is described as the biggest epidemic of the 21st century. There have been notable improvements in India in general healthcare, particularly in the control of communicable and infectious diseases but there are still considerable pressures from an epidemic of injury sweeping the country. Trauma care is neglected in most parts of the country and, if present, is very sub-optimal in those parts.
In India, trauma is the third leading killer, next only to cardiac illness and cancer. In the developed world, it is the leading killer of young persons in their productive years, from 1-44 years of age.
Increasing casualties
As recent statistics reveal, 95,000 casualties occurred in 2006 in India and a much larger number of temporary and permanent disabilities from road traffic accidents (RTAs) alone.
In 2007, 60 years after Independence, I am afraid we are yet to devise an organised and structured, functional centres to receive, stabilise and treat victims of all accidents.
What to do to decrease the number of accidents on roads and at workplaces/ homes?
In many parts of the world, trauma remains a serious problem without an appropriately trained specialist. A trauma care system can be defined as a planned arrangement of personnel and resources committed to the needs of critically injured patients in a defined geographical area. However, a trauma care system absolutely requires sufficient planning, training, organisation and maintenance.
Pre-hospital care is the weakest link in the entire chain of the Indian trauma care system. In hospital care, management of the seriously injured consists of the standard practice of Triage, resuscitation, observation and transfer for definite care.
Rehabilitation of the injured should ideally take place throughout treatment rather than relegated to the pre-discharge phase.
It would therefore seem opportune to consider whether the Advanced Trauma Life Support (ATLS) course should be introduced in India following China, Singapore, Hong Kong, Saudi Arabia, Thailand and Pakistan.
ATLS is a trauma care system which is didactic, systematic and is taught and practised in 41 countries since its inception in 1980 by the ACS (American College of Surgeon-Sub committee on Trauma) It has been shown that the ATLS Training for doctors and post graduates in a developing country has resulted in decreased injury mortality.
The following steps can be carried out to strengthen the weak links in the chain of trauma care in India.
A national or State-wide pre-hospital emergency care training care could be set up in partnership with private medical colleges which already run such undergraduate, PG courses, by suitably trained specialists, non-medical technicians and paramedics .
The concept of “platinum time”(10 minutes) to respond to the injured can be improved by assessment, sorting out (Triage) multiple casualties aided by Good Radio or GPS communication and centralisation of ambulance network.
A national “First Aid” and BLS (Basic Life Support) training programme can be started so that the care provided by the public can be improved.
The possibility of incorporating the principle of accident prevention, BLS and First-aid in the school curricula and during driving courses must be considered to create and understand trauma prevention.
Based on the Chinese model, rural and urban work places must be targeted for preventive care.
Formal courses
A formal postgraduate training in Emergency Medicine and Trauma care along the lines of those in the U.S., U.K. and China should be started though a few private medical colleges have readily established PG courses, programmes and certifications; the same should be recognised by the MCI (Medical Council India) and encouraged and supported by the Union and State governments.
An accelerated and systematic training and organisation of the paramedics and EMTs, availing the service of “trained” trauma care specialists and emergency physicians in partnership with private medical college hospital, IMA and SEMI (Society for Emergency Medicine India) should be done.
Encouraging International academic exchange in those areas of research and clinical practice that are relevant to Indian needs and resources must be done to compare with the data and outcomes in countries like China, Brazil and Pakistan.
A simple transfer of the system and experience of an advanced industrialised country is not always possible or appropriate; instead there should be a process of choice and utilisation tailored to the needs of our nation.
All the trauma care medical units should be brought together into a regionalised State/ National Trauma system so that an integral system can be developed and, more importantly, audited periodically.
The writer is a senior consultant at a private medical college and research institute in Chennai.
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