India Needs organised trauma systems : Dr Harish Kapila

dr.  kapila
      Dr Harish Kapila

Road accidents kill approximately 1,50,000 people per year in India out of a total of 500,000 accidents reported every year. Every minute a life is lost in road accidents in our country. We have an accident rate of 140 per 10000 vehicles compared to 2per 10000 in west.

Injuries rank fourth as a cause of death for all age groups in this country. It is the leading cause of death among children, adolescents and young adults. Injuries account for more premature deaths than cancer, heart disease or HIV infection.

Recent studies suggest a bi modal pattern of trauma deaths with a reduction in late deaths. The majority of all deaths still occur within minutes of the injury, either at the scene prior to arrival of medical emergency services, enroute to the hospital, or in the first hours of care. These immediate deaths are typically the result of massive hemorrhage or severe neurological injury.

Deaths represent only small part of injury disease burden. The amount of economic and social burden it entails is colossal. Injury accounts for 20% of years of potential life lost (YPLL) before the age of 65. This is more than any other disease like malignant neoplasm (15%) and heart disease (12%).

Definitive care for trauma patients is offered by government hospitals, corporate hospitals and a  large number of clinics across the country. Facilities that offer treatment for trauma patients, at different levels, report 10-30%  of their beds occupied by victims of road accidents. Most government hospitals offer free care but the quality of care differs from one centre to another. Most university hospitals provide a reasonable level of care. These hospitals are able to fulfil the role of tertiary care centres but critical care remains a weak link in such settings for a variety of reasons. Private and corporate hospitals, located mainly in big cities, are well equipped, offer good operating facilities and intensive care units. But, few run dedicated trauma services. There are no norms to govern their standards of healthcare delivery.

Problems due to lack of organised trauma systems

  • Pre hospital care in most cities is non existent. Even if patients reach the hospital, the golden hour concept is still a distant dream.
  • Ambulances services are poorly organised and there is no centralised agency to monitor the services. The training of paramedics in the ambulances is an important concern.
  • Concept of “Triage” is followed in less than 50% hospitals. Casualty medical officers are the only physicians to provide resuscitation.
  • There are no dedicated trauma surgeons in India. Clinical decisions are often delayed in the absence of clear perceptions of responsibilities amongst different physicians.
  • Rehabilitation is mainly restricted to physiotherapy. Occupational rehabilitation is generally missing at most centres.
  • Finally, there is no central trauma registry in any institute.

What is the way out of this tragic situation.

The answer to above problems lie in having dedicated trauma centres in various cities across the country. A trauma system is an organised approach to acutely injured patients in a defined geographical area that provides full and optimal care and that is integrated with local medical emergency.

A trauma center is a hospital equipped to perform as a casualty receiving station for the emergency medical services by providing the best medical care for the trauma injuries, 24 hours. In order to qualify as a trauma centre, a hospital must have a number of facilities including a high quality intensive care ward and an operating theatre, well equipped in terms personnel and equipment.

Classification of trauma centres

Trauma centres are classified on the basis of resources available and the number of patients admitted regularly. These are categories that define the national standards for trauma care in hospitals.

Level I A level centre has full range of specialists and equipment available round the clock and admits a minimum required annual volume of severely injured patients. It has a programme of research and is a reference centre for other centres.

Level II It works in collaboration with level I centre. It provides 24hr availability of all essential specialties, personnel and equipment. It is not required to have a residency programme.

Level III It does not have full availability of specialists. It does have resources for emergency resuscitation, surgery and Intensive care of most trauma patients. It has transfer arrangements with other centres.

Level – IV – A level – IV center provides the stabilization and treatment of severely injured patients in remote areas where no alternate care is available.

Importance of treatment at trauma centres.

John Hopkins Bloomberg school of Public health and University of Washington conducted a research survey to study the effectiveness of treatment of a trauma victim at a specialised trauma centre against the treatment at a non trauma centre. The research provided convincing evidence to suggest the treatment of a trauma victim at a trauma centre reduces the risk of deaths by 25% for the injured patients. Review of multiple expert panel studies led to the conclusion that care delivered at trauma versus non trauma centre may be associated with less inappropriate  care, A significant reduction in preventable deaths in very severely injured patients was also noticed. Based on currently available evidence, the conclusion can be made that the development of trauma systems is important and must be supported.

Conclusion

Currently even the best emergency services and trauma systems are largely ineffective in preventing those deaths that occur at the site of accident. Efforts at preventing the occurrence of injury events or reducing the severity of injuries incurred will be the most effective means of reducing the large number of immediate deaths. Continued efforts at development of trauma systems that foster rapid and efficient means of triage and transfer to higher levels of care and research in the area of trauma, hemorrhage, infection will eventually serve to decrease the late and delayed deaths.

Dr Harish Kapila is Senior Consultant (General and Laparoscopic Surgery) at Max Smart Super Speciality Hspital, Saket, New Delhi1

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