A farmer in Nigeria is struck by a car and suffers multiple fractures. The sole breadwinner for his economically distressed family, before the accident this man had hopes of his children rising out of poverty. But it will take everything the family has saved to pay for his trauma care. Why? In so many countries families must pay for hospital treatment with their own, out of pocket resources. Due to a dramatic rise in traffic accident injuries, this economic burden of treatment often leads to multigenerational cycles of poverty. If your first instinct is not, “How awful! What can I do?” then think of it this way: the less trauma care these countries provide their citizens, the more the economically developed world will likely provide in the way of broader economic or other financial support.
Dr. Charles Mock, a general surgeon who has quite literally “written the book” on trauma care in developing nations, drives home the magnitude of the problem. Dr. Mock, who has worked extensively with the World Health Organization (WHO) says, “There are multitudes of individuals in the developing world who die from their injuries. But, for each person who suffers a fatal injury, there are perhaps 50 who survive and who are left to deal with traumatic injuries and their aftermath.”
Alarmed, as the year 2000 dawned, those at the WHO and the International Association for Trauma Surgery and Intensive Care (IATSIC) began to develop what would become known as the Guidelines for Essential Trauma Care (EsTC), recommendations that map out the basic elements of trauma care that should be accessible to everyone around the globe. Dr. Mock, a professor of surgery at the University of Washington in Seattle, states, “EsTC encompasses 10 core essential services that every injured person in the world should receive. In order to concretize these we developed 260 individual resource guidelines regarding life threatening and disabling injuries—resources which vary depending on the treatment level (clinic/small hospital/large hospital) and where the country falls on the economic spectrum. The guidelines, which can be utilized by whoever wants to advocate for change, are meant to serve as a basis for needs assessments. To date the EsTC recommendations have been used in 10 countries with some success.”
Dr. David Spiegel, assistant professor of orthopaedic surgery at the Children’s Hospital of Philadelphia and the University of Pennsylvania School of Medicine, has also participated in a WHO essential surgery initiative, a project that includes a trauma care component. And, after 15 years of volunteering “on the ground” in Nepal, Dr. Spiegel is a strong advocate for a broad, public health view of trauma care. He says,
Treatment for injured persons in developing countries will only improve if we approach trauma care in a comprehensive, system-wide fashion. To that end, health planners in developing countries would be well served by considering the Guidelines for Essential Trauma Care produced by the World Health Organization.
“The EsTC contains two checklists: a brief one that helps to identify major deficiencies and a full checklist of the 260 individual resource guidelines.”
“The checklists are sorted by levels of health care facility: a basic clinic, a medium-sized hospital with primary care physicians, a hospital that contains specialists, and a tertiary care facility. There are several categories of resources: essential, desirable, possibly required, and irrelevant. An example of an essential resource—one that should be provided at any type of healthcare facility regardless of the country’s economic level—is basic fracture care. Anything deemed essential was also done so because these are the most cost-effective ways of addressing trauma.”
Picking up the thread, Dr. Mock elaborates, “A resource that falls under the category of ‘essential’ would be something like a backboard or X-ray capability, things that are affordable in countries at all economic levels. ‘Desirable’ resources include those such as image intensification. These are items that add value, but are costly and not as universally applicable as the essential items. These guidelines have been used to undertake the assessment of trauma care capability in Vietnamese clinics and hospitals, with measurable improvement shown. Specifically, they were able to demonstrate an improvement (especially in the larger hospitals) with regard to skills training, as well as some basic supplies like materials for spinal immobilization.”
Dr. Spiegel acknowledges that most surgeons in advanced countries are not often given to thinking about the politics and workings of global trauma care. But if they were to get involved, he says, they would find another exciting initiative that has a real chance of changing the trajectory of lives and communities. “In 2004 the WHO initiated the Emergency and Essential Surgical Care Project, an effort to improve global healthcare with regard to surgery and anesthesia. This was the culmination of the WHO’s recognition that surgery plays an important role in population based health care in developing nations’ provision of primary health care.”
“This multifaceted project addresses not only what needs to be in place for safe surgery and anesthesia in terms of infrastructure, physical resources and supplies, but also training in essential interventions, ” says Dr. Spiegel. “The materials are directly applicable at the level of the district health center and represent services that should be available to all members of a society, such as Cesarean section, splinting a fracture, or draining an abscess. You can imagine the challenges in determining what constitutes ‘essential, ’ or services that should be universally available, keeping in mind that the majority of district hospitals are staffed by either general physicians or paraprofessionals who have received little or no surgical training. In Malawi, for example, nine trained orthopedic surgeons serve a population of 27 million. The majority of orthopedic services are provided by trained paraprofessionals or ‘orthopedic clinical officers.’”
Those in the know understand that in lesser developed countries you must work with what you have, but, in order to make improvements that last lifetimes, you must also strive for more. This means that any plan to improve global trauma care must include a training component. Dr. Mock states, “The needs assessments carried out as part of the Essential Trauma Care project have shown a severe limitation in the extent of use of continuing education for trauma care, both for doctors and nurses. Such continuing education courses (e.g. CME) can play an important role in strengthening trauma care and should be much more widely utilized. Generally, these would be two to three day CME courses whose goal is to provide a baseline level of training on how to care for injured people. These include information on what anyone in an ER should know about recognizing a limb threatening injury, how to recognize major fractures, how to handle spinal immobilization, etc. Depending on local needs, these courses could be extended to include more definitive care.”
Dr. Mock has also been encouraged to see other evidence of growing knowledge and skills.
The university I used to work for in Ghana has run a week-long course for the past 15 years that emphasizes fitting trauma care to the needs of rural doctors. Under normal circumstances, even when a referral is possible, it takes two to three days to arrange, meaning that skilled irrigation and debridement of open fractures is critical in order to prevent infection. It is very positive to see—from the nature of the referrals—that the patients arriving at tertiary referral centers are in better condition these days. Whereas the doctors used to get patients with open wounds that had gone untreated for three days, conditions are now much improved.
So what is interfering with further progress in global trauma care? Dr. Mock: “The fundamental goal is to improve the quality of care without spending much more money (because there is already a substantial amount of funding being spent). To a great extent this means that improvements in program planning are needed. The most recalcitrant problem, however, is just human nature…inertia. Everyone is busy and it takes a ‘squeaky wheel’ to get things done, especially with severely limited budgets. Not surprisingly, another obstacle is how to pay for equipment and supplies. In many countries patients must pay for implants, surgery, and medications upfront and in cash. When you are dealing with life or limb threatening injuries, however, that means a lot of people won’t get the treatment they need. Simple improvements in hospital finance mechanisms could change this problem, at very limited cost.”
Stay tuned for a follow up article about what specific countries are doing to improve trauma care for their citizens.
