Sunday Times 2
Preventing road accidents: ‘Revolutionary’ change need of the hour
View(s):By Dr. Kirthi Abayajeewa
We hear of the daily loss of life on the roads in the media. It is so common that this news is not ‘news-worthy’ any more. People have become naïve to most of these incidents around them and carry on with life. Is this loss of life really necessary; can’t we do some thing to prevent it?
Trauma is the commonest cause of death in 4-40 age group. We have lost 2,800 lives up to date this year. This is almost one death every 2.5 hours. Another ten fold get severely or permanently injured. In comparison we have lost approximately 60 lives to dengue during the same period. Do we care enough for accident prevention or do we really consider these deaths preventable?
According to WHO statistics Sri Lanka has a high per capita accident death rate. It is 17.4 per 100,000 of the population. This is a five-fold figure compared to an advanced regional country like Singapore in which the rate is around three. Motor vehicle crashes in developing nations account for 80% of all the motor crashes in the world. More alarmingly this figure is projected to double in just around five years time according to WHO studies.
Tri-modal pattern of deaths
Historically if you plot all trauma deaths on a graph, you find a typical tri-modal pattern of deaths.
Most deaths, up to 50%, occur a few minutes after the accident. These victims will never reach a hospital or health facility alive. The only way one can stop these deaths is by preventing them happening. One cannot over emphasise the need for road safety regulations and implementing them. In our country, we may have adequate rules but implementing them seems to be highly deficient.
The golden hour
Next, the second peak of deaths (approximately 30%) occurs in the first few hours after the incident. This time window is called the ‘golden hour’ in medical jargon simply because if treated properly a good percentage of these could be saved. Most of these patients would reach a hospital and if hospitals are well equipped and ready to receive these patients, that would make a difference between life and death. In fact the most number of ‘preventable’ deaths occur during this period.
A good pre hospital ambulance service is another major life saver for this group. Timely retrieval from the site, resuscitation and transportation will sustain their life in a salvageable state. This will be a drastic improvement from the current popular mode of transport namely the three-wheeler ride.
Triage
In modern trauma care, all patients received in a trauma centre are subjected to a process called ‘triage’, which literally mean sorting out. This is done at the entry point of the hospital by a trained person and completed within seconds. The patients are categorised in to three groups according to their severity. The most serious patients who are ‘priority one’ (P1) are treated in special room called the trauma shock room or resuscitation room. The less severely injured (P2, P3) are sent to designated areas and treated accordingly. Hence ‘first come-first serve’ is not always practised in a trauma units, especially when severely injured patients are admitted, for obvious reasons.
Advanced trauma life support (ATLS®) protocol
Once such a patient is received by a hospital, the first few minutes of management have a greater bearing on the outcome of a patient. Recognising this, a worldwide protocol driven management system has been developed to recognise and treat life-threatening conditions. These protocols are based on the fact that whatever the cause of the incident, deaths occur in a very orderly manner with systematic failure of airway, breathing, circulation, nervous system etc.
One such system developed by the American college of surgeons, namely the ATLS® protocol, was based on a real life experience of a surgeon who lost his wife and got himself and his three children injured in a private aeroplane crash.
This methodology has been embraced worldwide in over 60 countries, and has statistically been shown to reduce deaths. The College of Surgeons of Sri Lanka together with the Ministry of Health is in the process of promulgating this program in Sri Lanka. This may reduce some of the preventable deaths that occur in this country in the years to come.
The third peak
The third peak of deaths occurs after days to weeks and death is due to of multi organ failure infections mostly in Intensive Care Units. Saving all of these lives is impossible and for each life saved a huge cost will be incurred by the health system. A very high level of critical care too is essential to salvage this group. If some of these patients were treated initially in a timely and orderly manner they may not even enter this phase of illness. Hence prevention as well as proper primary trauma care are the two interventions that may reduce the mortality of this category.
Two arms
Reducing road accident deaths encompasses two main arms of action, namely the prevention of accidents happening and prompt treatment of accident victims.
USA, in mid 20th century showed how the preventive aspect could reduce road deaths. A similar situation to the present Sri Lankan scenario existed in the United States in the 1960s. With the massive expansion of the road network and vehicular transport, a large number of accidents and deaths were witnessed. The attitude towards victims was that death and disability was not a preventable phenomenon after trauma.
But authorities started to look critically at the outcomes. After major brainstorming, deficiencies in road users, the roads themselves and regulations were identified. As remedial action new regulations such as seat belts, a ceiling on occupants per vehicle and speed limits were changed. Roads were improved with speed limits unique to each road condition. More importantly accountability of drivers was brought in with point system on the driving licences, with a risk of cancellation of the licence when a certain penalty limit was reached. CCTV camera usage for monitoring drivers too was a major factor affecting the driver mind set.
The changes revolutionised the attitudes of road uses with resultant significant reduction of collisions and deaths. More importantly these brought about a decent culture among road uses with respect to each other.
UK, more recently revolutionised the treatment aspect of road accidents. Similar to Sri Lanka, UK hospitals were not geared to treat major trauma victims till the dawn of this millennium. Identifying this, a NCEPOD (National Confidential Enquiry into Patient Outcome and Death) report in 2007 clearly identified that the chance of survival and completeness of recovery was highly dependent of the care that followed. They created centres of excellence of trauma care in designated cities throughout UK called ‘Level I trauma care facilities’. These were separate from the routine Accident and Emergency units that already existed. Most major victims were channelled to these centres by-passing numerous hospitals, which did not excel in trauma care. By the year 2012 UK was able to reduce major trauma deaths by one third of the previous figures.
Revolution
Che Guevara once defined a revolution as a ‘Change of heart’. In Sri Lanka what we really need is a change of heart or change in attitude not only by road users, but also health care providers. Good road user habits have to be engraved even if it costs popular votes. Strict road regulations have to be implemented even if people go on ‘strike’. Designated trauma facilities should be set up at the rate of at least one for each province and all major trauma patients directed to these units. Targets of survival have to be assigned at national level and appropriate hospital upgrades and mandatory trauma care training programs have to be implemented in these facilities. Ironically all these are achievable with the currently available resources and manpower. So we are really in need of a revolution in that sense.
(The writer is a Senior General Surgeon at the Accident Service of the National Hospital of Sri Lanka.)