Want a challenge? Try improving the trauma care of everyone in the world. That is what a brave few have undertaken, in partnership with global entities such as the World Health Organization (WHO). With an upsurge in vehicular accidents and a hodge podge of trauma care resources, lesser developed countries still have a long way to go.
But they do have champions…seasoned champions.
Dr. Charles Mock, a general surgeon who has worked extensively with the WHO to advance trauma care in developing nations, states,
The common thinking is that injuries largely occur in wealthy countries. The truth, however, is that injury mortality rates are significantly higher in most low- and middle-income countries.
“And with most of the world residing in low and middle income countries, that is a huge burden of disease for people with so little.”
“The good news, ” says Dr. Mock, a professor of surgery at the University of Washington in Seattle, “is that trauma care doesn’t have to be prohibitively expensive for these countries. One study from Ghana showed that of the number of Ghanaians who had an injury-related disability, nearly 80% involved the extremities. As such, we should be able to treat these injuries with low cost methods…in stark contrast to the head and spine injuries that occur in the more developed world.”
The other good news is that there are ways to work with what you have.
When someone is injured in Manhattan or Paris, pedestrians hear ambulance sirens…in rural Africa or India it is more often the sound of a taxi driver yelling, “Get out of the way.” Dr. Mock explains: “An essential part of improving trauma care involves some form of effective Emergency Medical Services. In many parts of the world, however, injured persons are usually taken to the hospital by some type of commercial vehicle, such as a taxi or bus. Such is the case in Ghana, where my colleagues and I undertook a study in which we trained over 300 commercial drivers in basic first aid. Then we assessed the efficacy of the course by comparing the process of prehospital trauma care provided before versus after the course.”
“Of the 71 drivers who were interviewed nearly a year later, 61% indicated that they had provided first aid since taking the course. Breaking down the components of first aid, we found substantial improvement in several areas: crash scene management (7% before vs. 35% after), airway management (2% vs. 35%), external bleeding control (4% vs. 42%), and splinting of injured extremities (1% vs. 16%). One of our ‘take away’ lessons was, ‘Work with what you have and improve on it.’”
When asked about how to approach this monolithic goal of improving trauma care worldwide, Dr. Mock responds with a question: “First of all, do you have a decent budget to work with? If that is the case, then the most effective way to improve trauma care in any one country is to implement The Guidelines for Essential Trauma Care (EsTC), a framework established by the WHO and IATSIC (International Association for Trauma Surgery and Intensive Care) that delineates the fundamental elements of trauma care that anyone in any locale on earth should be able to receive. We have shown in the literature that these guidelines are resulting in improved trauma care—and that they do not have to be prohibitively expensive.”
When trying to convince those who need convincing, be it “in-country” or at broader level, what does Dr. Mock do? “I show the data from Vietnam.”
Dr. Mock elaborates, “Perhaps the most concrete example we have of how improvements can be made in a low-cost, uniform manner comes from Vietnam, where we field tested The Guidelines for Essential Trauma Care with measurable, positive results. We conducted a baseline survey in 2002 that assessed trauma training for physicians and nurses, as well as planning capabilities—rural clinics, small hospitals, and large hospitals were all included. The survey was repeated a year later in order to assess the effectiveness of the training undertaken.”
“Compliance with the EsTC guidelines was noted as either: absent, inadequate, partly adequate, or adequate. The rural clinics showed some improvement in basic airway management and oxygen provision (went from absent to inadequate), but showed no improvement (i.e., remained absent) in areas such as advanced airway management or blood transfusion capability. Things were somewhat better in the small hospitals, with basic and advanced airway management, as well as use of oxygen and chest tubes, going from inadequate to partly adequate. Another small hospital improvement was the increase from partly adequate to adequate as regards use of IV fluids. Concerning large hospitals, we found that the training increased the knowledge of advanced airway management and use of chest tubes from partly adequate to adequate. There was also a shift from inadequate to partly adequate when it came to use of a cervical collar.”
“So much of the trauma around the world is preventable by using a few simple measures. Ensuring that these capabilities are available uniformly around the world is part of our responsibility as physicians.”
Dr. David A. Spiegel, assistant professor of orthopaedic surgery at the Children’s Hospital of Philadelphia, co-chaired the 2007 Association of Bone and Joint Surgeons/Carl T. Brighton Workshop. “This event was dedicated to musculoskeletal trauma in low- and middle-income countries, and brought together orthopedic surgeons and educators. The participants, who were primarily from developing countries, did not focus on the specifics of how to treat injuries, but instead dealt with the macro level issues, including the barriers to musculoskeletal trauma care in the lesser developed world.”
And given that the average surgeon in Kathmandu or Malawi doesn’t have the luxury of advanced training, human resource issues are a substantial part of the picture. “At the workshop we discussed how different countries design curricula for training not only orthopedic surgeons but also paraprofessionals and/or others who provide musculoskeletal trauma care, especially at the more rural and underserved areas. Some lower income countries in sub-Saharan Africa have no training in orthopedic surgery; in some countries, however, there are programs whereby a surgeon can briefly travel to a neighboring country to train.”
Looking Eastward, things are somewhat brighter. Dr. Spiegel states, “Nepal began orthopedic residency training in 1997 and is making great progress. Their programs tend to follow the Indian model, which involves an internship and then three years of orthopedic surgical training. While it is a shorter program than those available in the U.S. or Europe, the value of training in one’s own country is that you train for those injuries that are seen locally—and you learn to work with the resources that are locally available. Unfortunately, we are still left with the reality that approximately 50% of the medical graduates of a country like Nepal will leave for better-resourced areas.”
Thus, while the new expertly trained orthopedist on staff is ready to go, he or she can’t provide proper trauma care without at least a modicum of appropriate resources. “Having trained caregivers is only one piece of the puzzle, ” says Dr. Spiegel. “In 2007 the steering committee for WHO’s Global Initiative for Emergency and Essential Surgical Care designed a basic surgical questionnaire to assess infrastructure, supplies, and resources in the developing world. To date the findings in numerous countries have highlighted gross deficiencies in, for example, the regular availability of electricity and running water. A specific, depressing result was that only one in three hospitals had the capability to wash out an open fracture properly. Clearly, we—and I mean everyone at every level of healthcare—are not getting things right.”
Included in that “we” are the government officials and health planners, whose first agenda item for the day may not be to visit a rural health center. Local healthcare advocates, as well as Dr. Spiegel and his colleagues, are attempting to change that. “We have to convince government officials, those in the ministries of health and other stakeholders, that they can and should make a real difference in their people’s lives by implementing legislation aimed at preventing and treating injuries, and strengthening the availability and quality of emergency services available especially in the more remote areas of each country. The role of local healthcare advocates cannot be overstated, as they have the best chance of promoting their cause on an ongoing basis. The key is to frame the issue in a way that gets the attention of those in charge.”
We need to convince power brokers that inadequate treatment of musculoskeletal injuries leads to disability, catastrophic health expenses for families, and loss of economic productivity for the individuals and the society as a whole.
Dr. Spiegel, author of Bibliography of Orthopaedic Conditions in Developing Countries, reflects on what he would do if given a substantial grant. “I would take one district from a low income country and conduct community-based and facility-based surveys looking at the burden of orthopedic trauma in that district. I would also do a situational analysis of health facilities in that district, assessing the capacity and availability of services with regard to orthopedic emergencies. Are there nurses, general doctors, or general surgeons, etc? Then, I would proceed with developing a plan to make recommendations for the most appropriate way to upgrade the delivery of musculoskeletal care in that district.”
Then the white coats and others could complete their outfits by donning their advocacy hats.
