Jooma, Rashid

Khan, Sabeena Jalal

Razzak, Junaid

English

eCommons@AKU

eCommons@AKU Section of Neurosurgery Department of Surgery 10-2008 The trauma centre: What it should mean Rashid Jooma Sabeena Jalal Khan Junaid Razzak Follow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_neurosurg  Part of the Neurology Commons, Surgery Commons, and the Trauma Commons Vol. 58, No. 10, October 2008 530Four decades ago accidental death and disabilitywas described as the "neglected disease of modernsociety". In the intervening period, increased motorizationand violent civic strife has forced trauma onto centre stageof the global public health agenda and is now more oftenreferred as "the silent epidemic".1 The burden of diseasehas been manifest most overtly in developing nations suchas Pakistan where it is estimated 6.16 million unintentionalinjuries occur annually amongst persons of over five yearsof age.2 In a nationally representative household interviewsurvey, the overall incidence of injury was 41 per 1000 peryear for road traffic injuries.3 This is where the increasingburden is coming from and the ongoing Karachi RoadInjury Surveillance study has recorded 35,607 victims inthe calendar year 2007. These injuries from road accidentsreported to the five major emergency departments of theCity and the victims were largely males (90%). The roadusers involved were mainly motorcycle riders (65.3%) andpedestrians (21%) and 892 (2.3%) of the victims expired.4The rational response to this public health crisesshould be enhanced preventive efforts, taking cue from thedeveloped nations where, effective road injury preventivestrategies, some simple such as seat belt and crash helmetwearing and other sophisticated ones as traffic and vehicleengineering, have effectively controlled the human tollfrom road crashes. However, the current Health Policy ofPakistan5, makes no mention of injury prevention andcontrol and the thrust of our health planners is on provisionof acute hospital care. A lot of talk has of late beenforthcoming of trauma centres being built in chains alongmotorways and in urban areas but there is littleconsideration of Trauma Systems with an integratedcontinuum of prevention, prehospital evacuation of injured,hospital care and rehabilitation. This manuscript arguesthat the modern Trauma Centre should be more about asystem of injury management rather than a structure or anestablishment.Analysis of deaths following trauma haveconsistently pointed to the need for rapid transfer ofseverely injured patients to hospitals appropriate to theirneeds, concentrating expertise with direct involvement ofsenior clinicians in all phases of care and amultidisciplinary approach.6 The excellent Rescue 1122service of Lahore often experiences the mismatch betweena well-honed prehospital emergency service and a lethargicgeneral hospital emergency set up. The much touted 7minute response time of the ambulance service becomesmeaningless when the receiving facility is not geared tofast- tracking the definitive care of the injured. On the otherhand, one of Pakistan's better hospital-based emergencyservices in an audit of their trauma experience reported thatthey had an "unacceptably high" percentage of preventabledeaths and attributed this to inadequate and inappropriateprehospital care. No care provider properly trained tosecure the airway and control the cervical spine wasinvolved in the first response and arrival at the hospital wasnot pre-notified. Delays in the emergency room andindecision on the part of the admitting teams, often bereftof a senior clinician, were also identified.7 The essence ofthe Trauma Centre is the 24-hour availability and activationat short notice of the Trauma Team. This is a group ofhealthcare professionals with specific training inresuscitative trauma management and incorporatingphysicians, nurses and paramedical personnel. A qualifiedconsultant-level anaesthetist and a trauma surgeon shouldbe present in-house and one would function as the teamleader. The analogy must be to the medical team of acombat military hospital: specialists ready round the clockto minister to critical patients with complex injuries. Theteam would have immediate access to experienced doctorsfrom orthopaedics, neurosurgery, general and vascularsurgery, plastic and thoracic surgery able to make decisionsand intervene surgically as required. The deployment ofsuch a team is not possible without the trauma centrehaving a large pool of such specialists willing and paid tobe present in-house or available at short notice at all hours,in shifts, to the exclusion of private commitments.Preventable posttraumatic death and disability owes toinadequate resuscitation and delay in proper surgical careand these can be reduced by the system care of the traumateam rather than the infrastructure of the well constructedtrauma centre. The investigative and therapeutic infrastructure ofthe modern Trauma Centre typically has at least 6 to 12resuscitation bays each having complete facilities forEditorialThe Trauma Centre: What it should meanRashid Jooma1, Sabeena Jalal Khan2, Junaid Abdul Razzak3Department of Neurosurgery & Principal Investigator, Road Traffic Injury Research & Prevention Centre1, Emergency Medicine3,Jinnah Postgraduate Medical Centre, Karachi1, Aga Khan University Hospital, Karachi2,3.531 J Pak Med Associntubation with anaesthetic machines and ventilators. A24 hour CT scanning facility on-site is essential alongwith portable X-rays and ultrasonography and all withappropriate staffing and immediate reporting facilities.Dedicated trauma operating rooms should be availableand staffed at all times and these must be backed byintensive care beds. Such a trauma centre is organized andgeared to the purpose of immediate life-savinginterventions for the victim, by experienced personnel, tosecure and protect the airway, ensure adequate breathing,stabilize the circulation and minimize disability byprotecting the spinal cord from an unstable spinal columnand the brain from an expanding haematoma. That is theABCD of the Trauma Centre.Developed nations have responded with integratedTrauma Systems comprising of four elements that are allfunctionally linked in a continuum: a) a communication netto provide access to the system b) organized transport by aprehospital emergency system c) hospital services whichare configured to provide immediate resuscitation by aTrauma Team and definitive interventions by availablespecialists and d) rehabilitation services. The TraumaCentre is the crown jewel of this system and represents theapogee of a network of professionals deployed 24 hours aday, 7 days a week and devoted to ameliorating the effectsof severe injury by systemic, timely and expertintervention. It is these systems and networks that we needto evolve and construct as a necessary prerequisite to thecommissioning of the physical structure. References1. The World Bank. Injury: A Leading Cause of the Global Burden of Disease.Geneva. Switzerland; World Health Organization, 1999.2. Fatmi,Z, Hadden W.C, Razzak JA, Qureshi HI, Hyder A.A, Pappas G.Incidence, patterns and severity of reported unintentional injuries in Pakistanfor persons five years and older: results of the national Health survey ofPakistan 1990-94. BMC Public health 2007; 7:152.3. Ghaffar A, Hyder A.A, Masud TI. The burden of road traffic injuries indeveloping countries: the 1st national injury survey of Pakistan. Public health2004; 118:211-7.4. Jooma R. Unpublished data of one year Road Traffic injury surveillance studybeing conducted at five major hospitals of Karachi, 2008, Pakistan.5. National Health Policy 2001. The Way Forward. Agenda for Health SectorReform. Ministry of Health, Government of Pakistan, 2001.6. Walt AJ, Moxley JH 3rd, Mangold KG, Trunkey DD, Gann DS, Pisacano NJ.Panel: "Role of the specialist in the emergency room." J Trauma 1979;19:481-91.7. Jat AA, Khan MR, Zafar H, Raja AJ, Hoda Q, Rehmani R, et al. Peer reviewaudit of trauma deaths in a developing country. Asian J Surg 2004; 27:58-64.Original ArticleA study of adverse drug reactions caused by first line anti-tuberculardrugs used in Directly Observed Treatment, Short course (DOTS)therapy in western Nepal, PokharaAnupa Khatri Chhetri1, Archana Saha2, Sharat Chandra Verma3, Subish Palaian4, Pranaya Mishra5, Pathiyil Ravi Shankar6Department of Pharmacology1,2,4,5,6, Western Regional Tuberculosis Centre3, Manipal College of Medical Sciences, Pokhara, Nepal.AbstractObjective: To study the Adverse Drug Reactions occurring during DOTS therapy and to assess their causality,severity and predisposing factors. Method: Patients undergoing DOTS treatment during the 5 month study period (20th January to 20th June,2005) at the Regional Tuberculosis Center (RTC) in Pokhara, Western Nepal were studied. Patients and/orpatient party were interviewed to detect occurrence of any ADRs during their visit to the DOTS center.Causality and severity assessment were carried out as per the 'Naranjo scale' and 'modified Hartwig andSiegel scale' respectively. Statistical analysis (Chi square test) was done to determine the predisposingfactors.Results: Totally 137 patients were studied among whom 54.74% (n=75) reported occurrence of ADRs. Total29.33% of ADRs were reported by the age group 21- 30 years. Nearly half (49.33%) of the ADRs werereported by men and 33.33% were reported by the ethnic group of 'Gurungs'. Half (49.33%) of the patientswere illiterate and 70.67% of the ADRs were classified as ADRs 'possibly' due to the suspected drugs and93.33% were classified as 'mild (level 1)'. Isoniazid accounted for 49.3% of the ADRs. The most commonlyreported ADR was tingling and burning sensation in hands and feet experienced by 32 (11.03%) patients.Conclusion: Occurrence of ADRs from antitubercular drugs was high in the population of Western Nepal.Further studies encompassing a wider population and covering different regions of Nepal are needed(JPMA 58:531; 2008).

The trauma centre: What it should mean

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The trauma centre: What it should mean

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