Trauma Care in Resource Challenged Environments

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Trauma Care in Resource Challenged Environments

• Presenter Michael J Bullard MD
  Professor
• Department of EM
• University of Alberta

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Objectives

• Trauma the neglected scourge
• Cases for Discussion
• How do we deliver trauma care?
• Addressing the Needs in Taiwan Africa
• Understanding impediments to trauma care capacity
  building
• Summary

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Introduction

• Trauma leading cause of death ages 5 - 45
  everywhere except Africa (trauma deaths higher
  than west, but HIV/TB even higher)
• MVCs account for 2.2 of all global mortality
• 90 of all MVCs occurred in low - middle income
  countries

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Trauma Case 1

• A 20 year old male construction worker has a
  heavy object fall on his right leg causing
  significant deformity to his right lower leg with
  an open wound and active bleeding.
• In Edmonton describe what you would expect to
  happen prior to the patient reaching hospital.

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Ideally

• Control bleeding (assess distal pulses)
• Splint for comfort
• Transport by EMS to appropriate ED
• Initiate IV provide analgesia prn
• Take note of the scene looking for anything that
  may impact the EPs decision making (possible
  infectious materials, toxins, workplace safety
  issues, etc.)

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What about

• 100 km north of Grand Cache
• Taiwan in 1989
• Cape Town 2006
• Rural Africa 2006

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Differences

• Grand Cache
• If no company ambulance may be quicker to
  transport by truck. May use tourniquet whiskey.
• Taiwan

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Differences

• Grand Cache
• If no company ambulance may be quicker to
  transport by truck. May use tourniquet whiskey.
• Taiwan in 1989
• 119 ambulance, scoop run, no splint or bleeding
  control to nearest hospital, by fireman with no
  first aid training
• Cape Town

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Differences

• Grand Cache
• If no company ambulance may be quicker to
  transport by truck. May use tourniquet whiskey.
• Taiwan in 1989
• 119 ambulance, scoop run, no splint or bleeding
  control to nearest hospital, by fireman with no
  first aid training
• Cape Town
• EMS with bleeding control, splint, IV, /-
  analgesia
• Rural Africa

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Differences

• Grand Cache
• If no company ambulance may be quicker to
  transport by truck. May use tourniquet whiskey.
• Taiwan in 1989
• 119 ambulance, scoop run, no splint or bleeding
  control to nearest hospital, by fireman with no
  first aid training
• Cape Town
• EMS with bleeding control, splint, IV, /-
  analgesia
• Rural Africa
• Transport by private vehicle to bonesetter or
  nearest clinic/hospital. Probably control
  bleeding themselves using tourniquet

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What are the impediments to pre hospital care
improvements?

• 100 km north of Grand Cache
• Taiwan in 1989
• Cape Town 2006
• Rural Africa 2006

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Impediments

• Grand Cache
• Distance, personnel, cost-effectiveness
• Taiwan

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Impediments

• Grand Cache
• Distance, personnel, cost-effectiveness
• Taiwan
• Education, equipment, culture politics
• Do dswo, Do tswo
• Xiao dswo, Xiao tswo
• Bu dswo, Bu tswo

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Impediments

• Cape Town
• Safety, financial resources, cultural /
  historical
• Rural Africa

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Impediments

• Cape Town
• Safety, financial resources, cultural /
  historical
• Rural Africa
• Financial, human resources, education,
  tribal/spiritual/political
• Everywhere
• Traditional specialties will try to block change
  (issue of power control, feeling threatened)
• Often history of government distrust, leading to
  slow support of new system introduction or change

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Trauma Case 2

• Car left the road rolled.
• 26 y/o male thrown out is unconscious (noisy
  breathing) in the ditch with obvious hip
  deformity.
• 24 y/o male restrained driver trapped in car in
  obvious shock, pale, with open fracture of right
  lower leg, however, still conscious and alert.

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What can, and would you expect our medical system
provide pre-hospital for these patients?
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Trauma System Response

• Prehospital care
• Emergency access (911)
• First response capability
• ALS for ABC stabilization
• Extrication jaws of life
• Spinal immobilization
• Equipped ground ambulance
• STARS helicopter
• Communication system(s)

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What about

• 100 km north of Grand Cache
• Taiwan in 1989
• Cape Town 2006
• Rural Africa 2006

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Trauma System Needs/Responses

• Prehospital care GC T89 CT RA
• Emergency access (911) v v v
  X
• First response capability X X
  v X
• ALS for ABC stabilization v X v
  X
• Extrication jaws of life v v/2 v/?
  X
• Spinal immobilization v X v
  X
• Resourced ground ambulance v X v
  X
• STARS helicopter X X X
  X
• Communication system(s) v v/2 ?
  X

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In Edmonton what resources (capacity) can we
bring to bear for these patients when they reach
hospital?
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Trauma System Needs/Responses

• Hospital Care
• Emergency Department
• Trauma team (multidisciplinary)
• Advanced ABC
• If can stabilize, investigate
• If cant, to OR (Trauma Surgeon)
• ICU vs trauma ward
• Post recovery rehabilitation

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What about

• 100 km north of Grand Cache
• Taiwan in 1989
• Cape Town 2006
• Rural Africa 2006

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Hospital Resources

• Grand Cache
• FPs only, no CT scanner, U/S, or ICU
• Access to fixed wing air ambulance
• Taiwan

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Hospital Resources

• Grand Cache
• FPs only, no CT scanner, U/S, or ICU
• Access to fixed wing air ambulance
• Taiwan
• 1.1 physicians / 1000 population 827 hospitals
  with 4.1 beds / 1000 Canada 2.1 docs 981
  hospitals with 2.8 beds/1000
• ED trauma care same as Edmonton Calgary in
  the early 70s

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Trauma System Needs/Responses

• Hospital Care 1989 1998
• Emergency Department v/2 v
• Trauma team (multidisciplinary) X
  v
• Advanced ABC X v
• If can stabilize, investigate v/2
  v
• If cant, to OR (Trauma Surgeon) X
  v
• ICU vs trauma ward X
  v
• Post recovery rehabilitation v/2
  v/2

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Hospital Resources

• Cape Town
• Similar to North America, however, British system
  based where first line care provided by house
  staff (staff M-F 9-5)
• Rural Africa

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Hospital Resources

• Cape Town
• Similar to North America, however, British system
  based where first line care provided by house
  staff (staff M-F 9-5)
• Rural Africa
• Very limited support even if able to get to a
  district hospital
• 1.6 beds / 1000 0.04 physicians / 1000 pop.
• 80 trauma deaths in Ghana occur outside of
  hospital (reflecting lack of EMS)

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Trauma Care Needs in Developing Countries (ie
Africa)
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Trauma System Needs/Responses

• Prehospital care 2006
• Emergency access (911) I
  
• First response capability
  I
• ALS for ABC stabilization
  U/I
• Extrication jaws of life U
• Spinal immobilization
  U
• Resourced ground ambulance I
• STARS helicopter U
• Communication system(s)
  M
• M mandatory I important U unimportant
• Scoop and run still highly effective for urban
  trauma.
• Rural trauma needs ability to stabilize /or
  rapid transport

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Trauma System Needs/Responses

• Hospital Care 2006
• Emergency Department I
  
• Trauma team (multidisciplinary) I
  
• Advanced ABC M
• If can stabilize, investigate U
  
• If cant, to OR (Trauma Surgeon) M
  
• ICU vs trauma ward I
  
• Post recovery rehabilitation I
  
• M mandatory I important U unimportant
• Extremely important but will take years to
  develop.

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Conclusion

• Modern Trauma/EM care resource education
  intense
• Inappropriate for resource poor countries except
  possibly urban environments
• Emergency response system development may be wise
  to ignore the critically ill/injured
• Focus probably should be on patients with best
  chance of full productive recovery (i.e. stable
  transportable by existing means)

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Thank You

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