Monday, November 30, 2009

Traffic injuries and trauma care

In 2001, I climbed into a white jeep to travel from the international airport in Delhi to the town of Bhiwani, some 120 kilometers away. Piloted by a hired driver, the vehicle was groaning with suitcases and people. I was placed in the rear passenger seat, which I was lucky to have to myself, but to my horror there were no seat belts. Having read State Department Advisories about the state of Indian roads, I felt ill with fear. Sure enough, the following two hours were full of near misses.

Travelers to developing countries are faced with a grim fact of life for most people in the world: the roads are abattoirs, as lethal as any tainted water or malarial mosquito. Traffic accidents kill hundreds of thousands of people in low- and middle-income countries every year (and plenty of tourists as well). China, India's fast-developing high-population counterpart, is very badly off as well (though neither country has historically devoted much attention to researching the issue, contributing a shockingly low proportion of articles to the medical literature on trauma). In an article about China's air pollution in this month's Atlantic, James Fallows puts black lungs into perspective: “...The big threat to foreigners was not in the air but on the streets. ‘I tell my patients, the most important ‘medical’ step you can take is to put on a seat belt in a car, wear a helmet on a bike, and run for your life in crosswalks,’ a Chinese doctor said. Road safety is that bad. For the foreign diplomatic corps, the leading cause of death is traffic accidents. I worried every day about being mowed down by a bus, since they don’t stop at lights. My wife was run over in Beijing by a motor scooter that was going the opposite way down an eight-lane one-way road and was running a red light too. She’s fine now; the driver roared away, still against traffic, as soon as he climbed back on the bike.”

And so it went for us. Our driver caromed past every sort of vehicle and not a few animals, honking and playing chicken over and over again. We passed overturned trucks. One, I recall, was piled so high with bales of something puffy that it was taller than it was long--or would have been, had it not been lying horizontally. Who knew what had happened to the driver? I clung to the door with the flats of my fingers.

Public health experts consider trauma (and not just that caused by vehicles) to be a disease, one that disproportionately mows down young, fit breadwinners. As such, it is economically devastating. Five million people each year die of traumatic injury. The causes are many, including a culture of careless, aggressive driving; a lack of coordinated emergency services; and a lack of adequate personnel and infrastructure at hospitals. Survival rates are much lower in low-income countries, not only because there are more accidents, but also because victims have less of a fighting chance once they are injured.

Trauma care starts in the field with emergency medical services, then proceeds to the door of the hospital. There, even when doctors are available, many don't know where to begin when faced with a bloodied, flailing trauma victim. Advanced Trauma Life Support, or ATLS, is an orderly approach to caring for an injured patient. It helps doctors focus on what will kill the patient first, while ignoring less serious if more spectacular wounds. ATLS has been shown to save lives even in limited-resource settings. It's not everywhere yet, but at the moment courses are available in 50 countries, including Bolivia, Costa Rica, Pakistan, Thailand, India, and some other lower-resource countries.

But even where an ATLS-ready team is available to stabilize patients, there needs to be a before and an after. There need to be ambulances and crews that know how to move and transport victims safely. After ATLS, there need to be surgeons, operating rooms, blood banks, rehab centers, and so on. All of these things are in short supply in low-resource settings. I made it from Delhi to Bhiwani and back in one piece. But the likely fate of a rural accident victim in India or another poor country that lacks EMS, ATLS, and definitive trauma care haunts me.

Traumatologists are trying. The Essential Trauma Care (EsTC) project, an effort on the part of the World Health Organization (WHO) and the International Association for Trauma Surgery and Intensive Care, have attempted to come to grips with the needs and the resources of low-income countries. They have released sets of guidelines that are adjustable according to circumstance, which would seem to be a realistic and useful approach. A 2007 World Health Assembly resolution called on the WHO and governments to set up and strengthen trauma systems, and although resolutions alone are not enough, they may pave the way to action. Dr. Charles Mock, a trauma surgeon and WHO official, has written eloquently about concrete actions caregivers can take to build trauma infrastructure in the wake of the resolution. He instructs caregivers to remind governments of the resolution, urge ministries of health to pick someone to steer trauma efforts, cite its text when they apply for funding, and network extensively at conferences and meetings.

Sounds like more time on the road for caregivers in low-income countries. Let's hope their vehicles have seat belts.

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