Issues in FG’s planned new trauma centres

Trauma  Trauma is physical injury or wound that poses a threat to life, that may result in disability or serious ill health. It is now regarded as the neglected disease of modern society and is also, the costliest medical problem in the world. Injuries are caused by interaction of various factors; at the societal level, […]

Trauma 

Trauma is physical injury or wound that poses a threat to life, that may result in disability or serious ill health. It is now regarded as the neglected disease of modern society and is also, the costliest medical problem in the world.

Injuries are caused by interaction of various factors; at the societal level, they include low socio-economic status and cultural norms that support violence to resolve conflicts at the community level, factors involve poor safety standards in the workplace, unsafe roads, and easy access to weapons and firearms. At the level of family relationships, factors include a lack of care and supervision, physical abuse, and a ruptured family structure. Finally, at the individual level, factors comprise a history of aggression, alcohol and substance abuse.

The magnitude of traumatic injury as a public health problem is enormous throughout the world; in terms of years of productive life lost, prolonged or permanent disability, and economic cost. Every day, about 16 000 people die from injuries, and for every person that dies, several thousand more are injured, many of them with permanent sequelae. Injury accounts for 16% of the global burden of disease, this is especially notable in low and middle-income countries; with By far the greatest part of the approximately 90% of total burden of injury occuring in such countries. 

In Nigeria, the annual report of the Federal Road Safety Corps in 2014 showed a total of 10,380 road crashes, which involved 16,779 vehicles and claimed 5,996 lives with 32,063 persons injured. This is for road traffic crashes only, excluding assaults, armed robberies, communal clashes, and acts of terrorism among others.

Currently there is no injury management plan in Nigeria, with trauma care integrated into the health care delivery system, with no national lead agency to coordinate various components of trauma system and no mechanism of accreditation and professional development in existence.

Federal government s resolve on trauma 

The magnitude of traumatic injury in Nigeria and the current state of trauma management is what prompted the Federal Ministry of Health to decide on the creation of seven trauma centers nationwide to cater for emergencies. 

The minister of Health Prof. Isaac Adewole while speaking to some select journalist in Abuja on 23rd December 2016 said: “The issue of trauma center is not complex, but it is also not simple. We want to ensure that each of our hospitals has a trauma center no matter how small.”

“As part of evolution of what you can call an upgrade in the system, we are now creating specialized trauma centers and it is not peculiar to Nigeria……….” 

Already, the chosen tertiary institutions in each of the geopolitical zones through their Chief Medical Directors have been invited and the cost of the seven trauma centers was estimated at about N35 billion. 

Trauma center services

The services at a trauma center is the immediate treatment of injured patient by assessment of the patients condition rapidly and accurately, resuscitation and stabilization according to priority, determining whether the patients needs exceed a facility’s resources, arrange appropriately for inter hospital transfer and ensure optimum care at any point without deterioration during evaluation, resuscitation or transfer.

The Advanced Trauma Life Support ATLS has traditionally been the basis for the essential information and skills necessary to identify and treat life-threatening and potentially life-threatening injuries under the extreme pressures associated with the care of these patients in the fast-paced environment and anxiety of the resuscitation room. 

Often, trauma patients require emergency surgery as part of resuscitation, stabilization or definitive care.  These surgeries are frequently battles against time, in spite of knowing to do, there may not be enough time to do it!

Three important things happen when there is blood loss; blood clot to plug the hole, blood vessels constrict to divert blood to the vital organs and heart beat faster, breathing gets faster to try and increase tissue oxygenation. As bleeding continues the energy needed to do all these get used-up and the proteins needed for the blood to clot get consumed. Telltale signs of lost encounter begin to appear; heart rate slows, heart rhythm becomes irregular, and blood pressure drops and patient begin to ooze blood. Thereafter, strange things begin to happen; the body instead of making blood clots starts breaking them down. At this time, the heart might still be beating, blood may still be flowing, the brain may still be alive but death is inevitable.

Our responsibility through this process is to stop the bleeding, to restore and preserve the lost volume. Sometimes even in the best centers, with the best equipment and the best hands there is simply no time.

Science and engineering has attempted to even the odds in our favor, through better understanding of complex biology that happens at the end of life.

Now we don’t need to rely on cotton gauze, clamps and stitches to achieve hemostasis; there are a range of incredible dressings made from the factors that are needed to make the blood clot that can be applied even to a big hole in a big blood vessel and would seal it in a matter of minutes.

Patients with bleeding in non-compressible areas of the body like chest, abdomen and pelvis, traditionally had their chest cut-open to compress the aorta to temporize until definitive surgical management could be accomplished. Resuscitative Endovascular Balloon Occlusion of the Aorta REBOA offers a new solution. The procedure involves obtaining arterial access, passing a vascular sheath, floating a balloon catheter to the appropriate section of the aorta, and inflating the balloon to occlude blood flow from abdominal or pelvic injuries.

For difficulty in access and getting to the bleeding site in a hard to reach body site; brilliant engineering has provided a solution by the use of micro particles that are laden with clotting proteins that are self-propelling against the flow of blood by releasing gas bubbles to get to the last few crucial millimeters to the edge of the bleeding vessels.

In addition, the end of life process is being interfered with, in the battle to get more time; by delaying the process that leads to blood clot destruction, through the use of drugs that given early-enough after injury can ‘vaccinate’ against this process of cascade that lead to death. 

Another delay measure is to make organs and tissues more resilient; every tissue has a period it can survive completely disconnected from its circulation under optimal circumstances; cornea 14days, kidneys 20 hours, heart and lungs 5-6 hours. Brain is the most sensitive, with about 3 minutes at body temperature. 

This has been pushed-out more than 10 times by modern anesthesia and careful cooling to enable operation on major vessels that supply the brain with the brain completely disconnected of its blood supply by Neurosurgeons. It’s not unconceivable for such strategy to be applied for trauma surgery.

The satisfaction from the adrenaline, the setting, speed of decision and dissection, dexterity, skills-mix, knowledge-base and tactics required to resuscitate, investigate and operate a severely injured and bleeding patient successfully is unparalleled in any aspect of clinical medicine, and so also is the frustration from a failed venture.

In his epic paper, Don Trunkey an Emeritus Professor of trauma and surgical critical care at Oregon Health and science university established clearly the advantages of trauma care at a trauma center as far back as 1979. The report compared the results of trauma care in San Francisco County, a region where all patients are brought to a single trauma center, with the results of care in Orange County, where patients are brought to the closest receiving facility. One hundred consecutive victims of motor vehicle accidents were selected for the study from each region. The injured who survived long enough to reach a medical facility were examined to evaluate the effect of the hospital setting on the care rendered to victims of major trauma. The data showed that in Orange County a high proportion of the deaths might have been prevented If the victims had been treated in the trauma center. The  autopsy data clearly supported the concept.

Before trauma center; pre hospital trauma care

It is often possible to minimize the consequences of serious injury, including long-term morbidity or death, by promptly providing effective care at the scene and en-route to the hospital. 

Deaths from severe injury occur in one of three peaks: immediate deaths that occur quickly as a result of overwhelming injury; the intermediate deaths that occur within several hours of the event and are frequently the result of treatable conditions and delayed deaths that happen days or weeks after the initial injury and are the result of infection, multisystem failure or other late complications of trauma. 

The major benefits of prehospital care are realized during the second phase of trauma, when the timely provision of care can limit or halt the cascade of events that otherwise quickly lead to death or lifelong disability. Without prehospital care, many people who might otherwise survive their injuries may die at the scene or en route to the hospital. Most deaths in the first hours after injury are the result of airway compromise, respiratory failure or uncontrolled hemorrhage. All three of these conditions can be readily treated using basic first aid measures. 

Prompt prehospital care may also prevent a number of delayed deaths from trauma. Measures that are useful for preventing deaths in this phase include proper wound and burn care, adequate immobilization of fractures, support of oxygenation and blood pressure during the first hours after a traumatic brain injury, as well as other measures that reduce the likelihood of complications developing later. 

To be continued next week

Dr Usman A Gwaram is a former Head, Accident and Emergency Department of Aminu Kano Teaching Hospital, now a Consultant General/ Trauma Surgeon at National Trauma Center, National Hospital Abuja and currently on rotation at the trauma unit of Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa. 

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