|
TRENDS
IN THE SURGICAL MANAGEMENT OF ROAD TRAFFIC INJURIES
IN NIGERIA
Prof. B.A. Solagberu.
M.B.B.S (Ibadan), FWACS (Ortho), FICS
Background:
Nigeria is the 6th largest exporter of
crude oil in the world. It has an estimated
population of 140million people with over 70% of
them living in poverty. The major mode of transport
in Nigeria is road transport. Thus strategic
planning is required to properly manage expected
cases of road traffic injuries arising from our
roads.
Institutional Trends:
Zero level:
This was the period of colonial rule. Management of
RTls was essentially in the hands of the foreign
colonizing powers,
Initial Level:
Early local management of RTI victims was
concentrated in the larger University Teaching
Hospital centres of Ibadan, Lagos, Zaria, Enugu etc.
Later, other centres developed in skilled manpower
and infrastructure to enable proper care of these
injuries. These include various federal medical
centres across the country, state teaching hospitals
like those of Lagos and Osogbo as well as some state
general hospitals. Trends in Management:
The 4 'M's of management:
Manpower:
This is provided by institution based training.
Initially was composed mainly of foreign trained
doctors and other professionals, but now includes a
larger proportion of locally trained professionals.
This has also been made possible by the development
of local postgraduate training colleges (e.g. West
African College of Surgeons and the National Post
graduate Medical College) Materials: Effects
of time and history as well as various prospective
studies (including the Cochrane studies) have
produced improved methods of management of trauma
patien~s. Machinery: Continuous
development of modern equipment and machinery have
enhanced care of trauma patients.
Money:
This creates a significant gap between ilI3nagement
in high versus middle/low income countries because
of the relative lack of many of the above named
factors in the lower income nations.
History of RTls:
Britain recorded the first road traffic casualty
when Mrs Bridget Driscoll of Old Town, Croydon was
run over by a Roger-Benz car at Crystal Palace,
London on 17 August 1896. The first recorded
casualty f!'Om a road traffic crash in the US was a
68 year old pedestrian in New York in 1899. This
prompted an article in the New York Times with the
following quote: "What Is Becoming Of Our Lives
when A Citizen Cannot Walk On The Streets Without
The Fear Of Being Struck Down By One Of These
Speeding Machines?”
Various local and global efforts have been made in
trauma care development over the last century with
various milestones achieved. These include:
·
1922:
American College of Surgeons' Committee on Trauma
(ASCOT) was inaugurated. 1955: Identification of
road traffic injuries as surgical problems by
Zollinger.
·
1960:
Australia was the first nation to introduce the use
of crash helmets
·
1966:
NRC (COTCOS identified accidental death and
disability as the neglected disease of modern
society.
·
1970:
Australia introduced seat belts for use in modern
cars,
·
1974:
At the global level, the
27'"
World Health Assembly Resolution (WHA27.59) declared
RTA as a major public health issue and member states
were called upon to address the problem
·
1976:
Dr James Styner's airplane crash stimulated him to
develop the Advanced Trauma life Support (.A.TLS)
protocol for management of trauma patients.
In the same year, the West African College of
Surgeons organized a symposium with the theme:
"Care of the Injured", which addressed guidelines
for managing trauma patients, especially Road
Traffic Injury victims.
1985: The 2"" report of the NRC identified
the fact that attention being paid to trauma as a
health problem was insufficient.
•
1988:
The Federal Road Safety Corps (FRSC) was set up in
Nigeria to amongst other things, reduce the: rate of
road traffic crashes in
Nigeria.
·
1993:
Rep Eclward Markay (0, Mass) in the U.S proposed a
bill (Section 303 of Public Law 103.43) to allocate
improved funding for research into mad traffic in
July
2000:
The Violence and Injury Prevention department was
set up in the WHO Geneva.
·
2003:
AFRO took up an Injury Advisor
·
2003:
The United Nations' General Assembly passed 2
Resolutions concerning road traffic injuries (A/RES/57/309
GRSC & 58/9) Plenary on WRRTI on 14'" April
2004
·
2004:
The World Health Day Slogan for 2004: 'Rood
Safety is No Accident' (7'" April 2004)
·
2005:
3rd Sunday of November every year set aside by the
WHO as World Day for Remembrance of .Road Traffic
Injury victims.
Assignment of Roles:
Whose problems are road traffic injury victims?
·
Surgeons? Based on Zollinger’s assertion in 1955.
·
Public Health practitioners? Based on the 1974 World
Health Assembly declaration.
·
Government? Based on the United Nations resolutions
of 2003.
·
Looking at the 3 above, the burden of the surgeons
appears particularly heavy:
“ since we are the ones who must clean up the damage
and watch the eyes glaze over; we probably have the
most motivation to see to it that
trauma is stopped or at least limited.” Thomas K.
Hunt,
1980 (San Francisco, CA)
"We must assume the lead role in designing
a
strategic plan for the prevention and care of
injuries .... And bring together
all
interested parties
in
one organization"
Stewart Hamilton, University of Alberta, Edmonton,
Canada (President, Trauma Association of Canada)
1990.
The Magnitude of The Problem:
RTls are responsible for about 1.2 million deaths
yearly. This is likely to INCREASE significantly in
the next decade if we do not take urgent measures to
control the problem.
RTls are currently ranked the 9" globally leading
causes of DALYs and are likely to rise to be the 3"
leading cause by 2020. 90% of the DALYs in low
income countries are due to RTls.
RTI incidence is expected to DECREASE in developed
countries by the year 2020. The opposite is however
through for the developing countries with an
expected rise to 85% (WHO 2004)
RTI makes the poor poorer
·
-
through loss of family income in procuring
treatment, funerals etc;
·
from unearned income and;
·
- from the family members who abandon their own
work to care for the injured.
Why are the statistics poor?
Amongst the reasons that have been proposed are:
1.
Increasing motorization (vehicles less safe +
motorcycles): Mekky A. 1985: Acid Anal Prev
17:101-109 & Hyder A.A. 2006 Eur J Pub Health
16: 487-91
2. 2.
Increasing Population
3.
Increasing need to travel (Dev thresholdVasconcellos
EA 1999: Accid Anal Prev 31: 319-28.
4. Reducing/stagnand
alternatives to travel (Road carries 95% of
passenger traffic ~ in dev countries Largarde ,
2007)
5. Increasing use of the roads (even despite GSM·
communication, email, etc)
6. Stagnant number of roads despite increase in
volume of human and haulage traffic e.g.
Ilorin-Ibadan mad since the 1950s or earlier, new
express way only presently being constructed.
7. Worsening road furniture (even if stagnant
number, roads should have been maintained) 8. New
dangerous habits distracting observance of road
safety practice: mobile phone, in-cadilms.
9. Declining capacity of heatth care response &.
poor research capacity&. funding 10. Less responsive
governmental agencies (VIO/Traffic Div MTDsl
FRSC/ FMOW or MOW)
The major reason according to Dinesh Mohan (Volvo
Chair Professor Transportation Research &. Injury
Prevention Programme, Indian Institute of Technology
Delhi) is that
"The
traffic mix
in
Developing countries is unlike that
of
Developed countries".
In developed countries) roads are built with
adequate provisions made for pedestrians, cyclists
as well as motorists. This is unlike the situation
in developing countries where there is a confusing
mix of all road users jostling for space.
|
PHASE /
ELEMENTS
|
HOST(HUMANS)
drivers, pedestrians, passengers, cyclists |
VECTOR VEHICLE)
Car, bus, trucks
|
PHYSICAL ENVIRONMENT
Trunk A, B roads, Road designs, Markings,
maintenance, Expressways, Weather |
Other proposed reasons however remain
true
until proved otherwise by class 1 evidence. In
summary:
1.
Poor infrastructure
Inadequate knowledge/skill
2. Cultural practices
(e.g. a. use of turban vs helmets)
Others Causes of RTls:
A triad of causes has been a. identified: b.
1. Vehicles
a. a.
Pedal cycle
b.
b.
Motor cycle
c.
c.
Cars &. Buses
d.
Trucks and Articulated vehicles
2.
Hosts
a.
Drivers
b.
Passengers
c.
Pedestrians
3. Environment
a.
Roads
b.
Weather
Haddon's Matrix:
Dr Haddon (a physician and 'an engineer) proposed a
means of intervention for each of, the elements
involved in producing the crash at each phase (pre-,
during and post-crash).
|
PHASE ELEMENTS |
HOST (HUMANS)
drivers, pedestrians, passengers, cyclists. |
VECTOR (VEHICLE)
car, bus, trucks |
PHYSICAL ENVIRONMENT
Trunk A,B Roads, Road designs, Markings,
maintenance, Expressways, Weather |
|
PRE CRASH
(crash prevention) |
Education Enforcement Personality |
Type of Vehicle & Safety devices (Road
worthiness) |
Road Engineering Road Signs Day/Night,
Rains, etc.)
Protection |
|
CRASH
(injury prevention) |
USE OF RESTRAINTS IMPAIRMENTS |
Crash Worthiness Head rest/ Air bags
Side impact Maintenance |
Protection barriers Pedestrian crossings
Obstructions
Pot holes
Booby traps |
|
POST CRASH
(Life sustaining) |
Pre-morbid state
First aid skills
Access to medics/ Hospitals |
Fire Risk
Glass (fibre)
Body (plastic not metallic)
Ease of access |
Rescue facilities Congestion |
Trends in surgical management:
Various changes have occurred at the 6 levels of
management:
1. General concepts:
The previous nomenclature of road traffic
accidents, RTA
(suggesting an unexpected occurrence, happening by
chance) has changed to road traffic
injury,
RTI (which suggests a definable, correctable event,
with specific risks for occurrence).
In the past there was a lack of organized care, but
this has given way to an organized form of regional
care in most developed (and some developing)
nations.
Continuous training needed & obsolete knowledge
continuously gives way to newer, evidence-based
knowledge)
Emergency Room, ER reception and care: The initial
first aid given both at the scene of the crash, as
well as at the ER, has also been shown to
2. History taking in RTI:
• Scenes of the injury &. circumstances of the
injury have been identified as being important in
determining the types and severity of injuries
sustained.
Pre-hospital transport has also been identified as
being important especially in causing secondary
injuries which may worsen the prognosis of the
initial injuries.
3.
Physical Examination:
Dr James Styner, the Nebraska surgeon developed the
Advanced Trauma Life Support, ATLS protocol in·1976.
Various revisions and modifications of this have
revolutionized the assessment and management of
trauma Victims.
4. Investigation:
Investigation modalities have also been reformed e.
g. in blunt abdominal trauma, investigative
modalities for haemoperitoneum have evolved from
4-quadrant tap, to the Diagnostic Peritoneal Lavage,
DPL developed in
1965,
then to Laparoscopic DPL and In the
19905,
the Focused Abdominal Sonogram for Trauma, FAST and
Abdominal Computerized Tomography scan.
In head injury, investigative modalities have also
evolved from Plain skull
x·
rays in the past, to Air encephalograms and now,
Cranial Computerized Tomography scans etc.
5. Treatment: Operative and non operative
modalities for treatment have also passed through
many stages of development
• The concept of 'the golden hour' is now doubted.
The risk of injuries to others during the
ambulance's crazy journey to the hospital is more
relevant (Lerner & Moscati,
2001 )
• The place of rapid infusion of fluids in a
bleeding trauma patient has also been reviewed.
Excess fluid infusion prior to controlling ongoing
blood loss is now known to be counterproductive.
• Staged procedures are giving way to one stage
procedures (e.g. in bowel resection),
• Splenorrhaphy now advocated for most splenic
injuries with splenectomy being left as a last
resort.
• Cochrane Reviews on cervical neck immobilization
• Revolution in Plaster of Paris treatment and the
advent of External Fixation for open fractures.
• Emergency internal fixation for some categories of
open fractures
• Treatment of suspected intracranial hemorrhage is
now CT based instead of diagnostic burr holes.
• The C.R.A.S,H study don worldwide for
corticosteroi use in significant head injure, and
the ongoing Clinical Randomization of Anti-
fibrinolytic agents is Significant Hemorrhage/,C.R.A.S.H
2 study, using Tranexamic acid (antifibrinolytic
agent) for reducing bleeding in trauma patients.
6. Research & Training:
This is still very poor especially in low income
countries. A fewer bright spots are however present
e.g. the work of the Centre for Injury Research and
Safety Promotion, ClRASP in 1I0rin.
7. Injury surveillance:
This is an evidence-based public health model for
injury prevention:
In conclusion, it is clear that the management of
trauma patients, particularly RTI patients has
undergone significant change over time from primary
prevention up to definitive culture,
A
definite gap however persists between the standards
available in high income countries and, those
available in low income countries including Nigeria.
There is therefore a need to pull resources together
and work for the sake of our people. We should
develop a culture of evidence based medicine as is
practiced all over the world and join forces with
national and global initiatives to improve the lives
of our people
 |
Edited by,
Dr Ibraheem, G
Senior Registrar,
Orthopaedics and Trauma surgery.
UITH, Ilorin.
|
|
