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Serving Sri Lanka

This web log is a news and views blog. The primary aim is to provide an avenue for the expression and collection of ideas on sustainable, fair, and just, grassroot level development. Some of the topics that the blog will specifically address are: poverty reduction, rural development, educational issues, social empowerment, post-Tsunami relief and reconstruction, livelihood development, environmental conservation and bio-diversity. 

Thursday, August 11, 2005

Development of a trauma management system in Sri Lanka

The Island: 06/08/2005" by Shirani Hapuarachchi,MBBS, MD, FRCA President, The College of Anaesthesiologists of Sri Lanka

Trauma remains a leading cause of death worldwide. This is so whether it be in the developed world or in the developing world as in Sri Lanka. In the USA 145,000 deaths are reported annually. Sri Lanka a speck in comparison to US in size also records about 2000 deaths per year. It is also the leading cause of hospitalization in this country.

For the year 2001 the number of admissions to hospital was a staggering 544,905 which is a rate of 2910.7 per 100,000 population i.e a morbidity rate of 15%.

A study done at the Accident service of the National Hospital Sri Lanka showed that the commonest cause of trauma is road traffic accidents.

In Sri Lanka with a population of 18 million 722 thousand the number of road traffic accidents in the year 2001 was 52057 and in 2002 it in fact increased to 55031.

The mortality rate remained around 2000.

We all agree that this is quite a substantial number when we consider the fact that they are fit, healthy and young. This is a sad fact. The incidence is highest in the first four decades of life. In most instances the victim is struck at the most unexpected time while getting about their daily chores, whether it be getting to their work place when it comes to bread winners or marketing or shopping when it comes to the house wives or it could even be school children on their way to school or back from school, in other words they are fit and healthy individuals getting about their daily activities otherwise they wouldn’t be on the road.

If we look at the statistics of admissions to the National Hospital Sri Lanka which is the premier Teaching Hospital in the country and which has the biggest Accident and emergency unit of the country we see over 100,000 patients seeking treatment each year. Of these about 25,000 are admitted. Which goes to show that `BC of almost all accident victims seeking treatment are serious, needing admission. The deaths have accounted for nearly 600 patients, which is about 15% of admissions.

But is this all? What about the long term morbidity or disability?. Though statistics are not available it is about three times that of mortality.

Disability at times may even be worse off for the next of kin than death as the patient needs to be cared for, for considerable periods of time. In fact the problem becomes even greater if the victim is the sole breadwinner of the family. The entire family can thus be suddenly plunged to the depths of despair.

What about the expense to the state? In a country like ours where health services are free the expenditure to the state is enormous .In fact statistics show that traumatic injuries are the leading cause of hospitalization in most districts except in Killinochchi, Mulativ, Vauvnia and Batticoloa. This is mainly due to the reduced number of vehicles on the road in this part of the country due to the war that existed but still, it ranks a close second.

What about the human suffering?

In my experience as a Neuro Anaesthetist getting involved in Neuro trauma from 1993 I have seen the mortality and the morbidity the young dying and the suffering caused by disability. The young with severe head injury dying, the salvageable ones some of whom ending up with severe functional disability, The victim of spinal injury conscious but unable to move, not even a flicker of a finger. Can you ever imagine? Living day in and day out at the mercy of others.

I think the need for improved care of the injured has become all the more important today as has never been before.

Care of the injured and the critically ill

I am a great believer of prevention better than cure. What can we as medical personnel do in this regard?

The common causes of road traffic accidents have been shown to be due to

1. Improper over taking - Have they been

assessed correctly at the time of granting the license. Has the Registrar of motor vehicles who issues driving licenses looked at it or given it serious thought.

2. Drink driving - When police bring them to us for assessment. Do we assess them properly breathalyzers, are they used adequately.

3. Excessive speeding – Don’t we have speed limits? Or are we not bothered to adhere to them?

In fact it has been reported that deaths in motor cyclists and pillion riders following the use of helmets have reduced. Pedestrian deaths too have reduced. Both these can be attributed to good education by the traffic police, introducing road regulations to the school curriculum and so on.

But there are many more preventive measures to be carried out. Spot fines by the traffic police a very simple procedure that will not only discipline drivers but earn a revenue to the police department.

Prevention does not mean preventing accidents alone but preventing morbidity and mortality following an accident. This is where I like to dwell a little. This is where we have concentrated our thinking and have put into action very many plans.

Injuries when sustained can be broadly divided into two categories.

1. The Primary injury that takes place at the time of the impact. As for this there is nothing we can do except the preventive measures that I highlighted and are being carried out commendably by the city traffic along with the Colombo Municipal Council and the education department.

2. The secondary injury - this is the worsening of the existing injury due to causes other than the impact.

What are these causes - deprivation of Oxygen, .Accumulation of carbondioxide and non respirable acids. Improper transport, further aggrevating the injury.

A survey done in the Accident and emergency unit of the National hospital showed that the majority of accident victims are brought to hospital in three wheelers by bystanders. And as you are well aware this is the worst mode of transport especially for an unconscious patient, patient with head injuries and of course to the spinal patient whose only chance of survival is also reduced to a minimum.

Our priority is to reduce the morbidity and mortality associated with road traffic accidents and if we are to do this we need to put a trauma care system into action. This should consist of 1. Prehospital Care 2. proper evacuation and transport of the injured 3. resuscitation and Primary trauma care 4. Definitive care in a trauma center if necessary5.rehabilitationof the disabled 6.and Quality management of the system.

Pre Hospital Care

Pre Hospital Care is the start of a continuum of care that forms the trauma chain. It is easy to under estimate how long it takes to move an accident victim to hospital.

Even for efficient emergency services it has been found that there could be a delay of up to half an hour between the time of the accident and arrival at hospital. This is the most crucial time as far as medical attention is considered. The golden hour which determines the outcome of patients is therefore spent to a considerable extent on the road or at the road side. The golden hour therefore becomes a pre hospital event.

This prompted us to start a proper evacuation method by ambulance for all accident victims in the city of Colombo. His worship the Mayor of Colombo, The chief medical officer of health both readily agreed with our proposal without any hesitation. I must also mention the Fire Chief who readily agreed to part with some of his new fire officer recruits 30 in number to be trained as para medics.

The training was carried out in the Colombo municipal council as well the National Hospital of Sri Lanka and Colombo South Teaching Hospital by the consultant Anaesthetists So now for the first time in the history of Sri Lanka we will be able to implement a proper 110 toll free evacuation system like in the west..

Colombo city will be divided into 4 zones – North, South, east and west. 4 ambulance stations will be established so that the response time can be reduced to a minimum. There are no evidence based studies as to the best response time but in the developed countries it is around 10 minutes.

Here in Sri Lanka the experience with fire calls is about 07 minutes. But this will depend on how busy the emergency service will be after a while and the extent of traffic in the streets of Colombo. The call 110 will be monitored by a central Alarm center and will notify the ambulance station nearest to the accident site The patients can therefore be taken to hospital – National or Colombo South (where accident and emergency units are established at present.) which ever is close by thereby reducing arrival time at hospital.

Transport of the injured

Patients should be packaged for transport to reduce further injury or secondary injury. They should be transported with a hard cervical collar, head blocks, limb splints and a body splint such as a SCOOP stretcher or a vaccum mattress. Spinal immobilization is a standard practice worldwide. It is also essential that hypoxia during transport is prevented by oxygen administration and monitoring the patients as regard oxygen saturation heart rate or pulse rate, blood pressure and the adequacy of breathing.

This will not only ensure adequate oxygenation but an adequate cardiac output as well. Equipment for transport should also be available in the ambulance. A source of oxygen, suction apparatus, Pulse oximetry, ECG and a defibrillator. A Blood pressure apparatus and Intravenous infusions are a must. If these patients have life threatening injuries which will not keep them alive until they reach hospital these too should be attended to. This is where a doctor will be of help in the ambulance. He should carry out a primary survey and life threatening conditions should be attended to while reducing externally visible bleeding and rendering first aid to minimize any secondary injury which might be too late to attend to by the time the patients arrive in hospital.

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