India and the Management of Road Crashes ... - Alfred Hospital

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To address the prehospital phase of care, activities to reduce accidentsand the development of patient transport and ambulance services for traumaare a high priority.For the hospital phase of care, the establishment of Tertiary TraumaCentres; increasing staff numbers and experience at Trauma Centres; trainingstaff in trauma reception and resuscitation; supplying adequate equipment andan adequate supply of drugs to Trauma Centres and developing computeriseddata collection and record keeping are required. These major teachinghospitals need to be developed to form the hub of an integrated traumasystem - providing 24-hour trauma reception teams, on-site neurosurgery,cardiothoracic surgery, intensive care and other specialist resources to deliverdefinitive care to the majority of the India’s major trauma caseload throughprimary triage from the accident scene or following secondary, inter-hospitaltransfer. Caseload concentration facilitates the development of a core groupof surgeons, anaesthetists and nurses who consistently manage large traumavolumes. Level 1 Centres are required to develop the resources and expertiseto deliver leadership and support to the trauma system as a whole.Trauma System DevelopmentThe evolving burden of injury has prompted the call for the development oforganised Trauma Systems in India [19,20] . A ‘Trauma System’ comprises anintegrated, protocol driven system of care which monitors and addressesPrevention, Notification, Prehospital care, Hospital reception and resuscitation,Surgical care, In-hospital care and Rehabilitation.Optimal care of trauma patients requires an organised approach thatrecognises the complexity and time-critical nature of major injuries. Theconcept of modern trauma systems originated from experiences with themanagement of soldiers injured in the Korean and Vietnam Wars - whenevacuation by helicopter and refined prehospital care enabled rapid transportof patients to definitive surgical care centres and greatly reduced militarycasualty deaths [21,22] . This encouraged the development of a landmark statewidesystem for treatment of civilian motor vehicle crash victims in Illinois inthe early 1970’s [23,24] .There is substantial evidence to support the concept that the timely deliveryof seriously injured patients to centres experienced in the management ofmajor trauma optimises outcome. Implementation of a trauma system inOrange County, California improved the quality of trauma care delivered andthe proportion of deaths judged to be potentially preventable decreased [25] . InOregon, trauma system development led to an increased proportion of traumapatients treated at Level I trauma centres and substantially improved thesurvival rate [26] . In San Diego a preventable death rate of 22% in 1984 fell to2% after trauma system implementation [27] and studies from New York Statedemonstrated a significant decrease in region-wide trauma mortality aftersystem development [28] . By March 2003, 35 U.S states had implemented atrauma system.8
Although in India there is no national lead agency to co-ordinate variouscomponents of a trauma system [29] , individual States have the opportunity tocorrect the almost complete lack of organised trauma care - and to address thelack of appropriate health infrastructure - through the formulation and adoptionof State Trauma Systems.As previously indicated, evidence indicates that people with life-threatening- but potentially treatable - injuries are up to six times more likely to die in acountry with no organized trauma system than in one with an organized,resourced trauma system.Road crashes are a significant risk to the lives of all road users.Trauma does not discriminate. Effective trauma care demands immediateresponses from trained emergency nursing, medical and technical staff.Trauma Systems have been developed to improve outcomes. However, thedevelopment of a comprehensive trauma care system is expensive. Aconstant concern is ‘…how can you indiscriminately treat first and recoup costslater..?’A comprehensive review of the requirements and establishment of a StateTrauma System can be found in a recently published article in Injury [30] . Thestrategic principle of “the right patient to the right hospital in the shortest time”provided the basis for the plan. The article reviews the designation of specifichospitals of various levels to care for trauma patients; the concentration oftrauma expertise at these centres; integration and coordination between theservice providers; development of agreed triage and transfer protocols andimproved education, training and research programs. A state-wide majortrauma database was established to enable system monitoring and facilitatefurther enhancements. This experience with the development of an integratedtrauma system should aid in the development of Indian State TraumaSystems.There are two key requirements for the establishment of State ‘TraumaSystems’.The first requirement is policy development which recognises the socioeconomicburden of injury and commits governing institutions to reformpresent, inadequate systems of care. The requirement for policy developmenthas already been stressed by the World Health Organisation [1,2] and needs tobe continually stressed by interested parties - including surgical andassociated medical groups who shoulder the burden of care.The second key requirement is funding. An ongoing, guaranteed fundingstream is crucial to Trauma System development.Funding for Trauma SystemsTrauma care is expensive. It has been shown that trauma mortality isinversely proportional to a country’s per capita gross national product [3,31] .9
Page 1 and 2: India and the Management of Road Cr
Page 3 and 4: IntroductionAccidental injury is on
Page 5 and 6: trauma. The two key physical causes
Page 7: As previously mentioned, the lack o
Page 11 and 12: A statutory authority, or equivalen
Page 13 and 14: References1 World Report on Road Tr
Page 15: 27 Eastman AB. Blood in our streets

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