Guest Editorial : Aadil S. Chagla

 

THE NEED OF THE HOUR: TRAUMA CENTERS along the National Highways

 

It is important to note that Maharashtra and Goa are among the states with the highest number of deaths caused by road traffic accidents (Figure 1).

TC- Oct 2016 - 001 - Rate of Accidental deaths in India

National Highway (NH) 17 which connects Mumbai (Panvel) to Goa, now renamed as NH 66 (Picture 1) has the maximum number of road traffic accidents and is often referred to as the “Highway of Death.” (Picture 2).

Needless to say, it is the poor quality of the roads, along with the lack of proper safety requirements such as road dividers and reflectors at the turns, too many blind turns, and only two-lane traffic that make this highway one of the most dangerous to drive . I wonder at whether one can call it a highway at all! As it happened, on the night of August 2, 2016, I was travelling on this very highway with my mother and sister’s family returning from Kudal to Mahad via Chiplun. We crossed the Savitri river bridge at about 11.15 pm. It was only later that we learned that this British-built bridge (which was over 90 years old) had outlived its life and collapsed around 11.25 pm killing over 40 innocent lives; two State Transport (ST) busses, at least half a dozen private cars and a couple of two-wheelers plunged to their death over the broken bridge (Picture 2). We must have been among the last few travelers to have crossed the bridge before it came down on that fateful night and are very fortunate to be alive today! It is pertinent to note that the old British bridge over the Savitri river, in spite of repeated warnings of collapse, was left open to traffic! All that was necessary would have been for the authorities to have closed that bridge as there was a parallel newer bridge (Picture 2) which would have managed the traffic well, as it is doing today. Had the authorities taken appropriate measures, many hapless lives would have been saved. It may be relevant to state that NH 17 (or now NH66) has many old bridges and also the bridge over the Zuari river connecting North and South Goa is also in a debilitated state. Unfortunately, the government instead of building a new bridge over this Zuari river, is building the third bridge over the Mandovi river and that too at an exorbitant cost!

Article 47 of the Indian Constitution states that it is the “Duty of the State to raise the level of nutrition and the standard of living and to improve public health…” Unfortunately, only about 1% of the total gross domestic product (GDP) is spent on healthcare in India, which is half that of China, which plans on increasing it to about 3 to 4%. Even Brazil has an expenditure on health of around 3.5% of its GDP. The US spends 17 % of its total GDP on health!

I would like to mention at this point that 70% of our 1.3 billion population live in rural India. Fifty percent of Indians still do not have proper shelter; 70% do not have access to decent toilets; 35% of households do not have a nearby water source; 85% of villages do not have a secondary school; over 40% of these same villages do not have proper roads connecting them.

Some more astounding facts:

1) Trauma is the third most important cause of mortality in India and is the most common cause of death among individuals younger than 40 years.[1]

2) Worldwide about 1.2 million civilians die as a result of road traffic accidents.[2]

3) In India, the available trauma care services are restricted to major cities, thus resulting in an increased incidence of deaths from traffic accidents.[3a &3b]

4) India has just 1% of total motor vehicles in the world, but these account for 6% of the global road traffic accidents.[4]

5) The severity of road accidents, measured in terms of persons killed per 100 accidents, has also increased from 20.8 in 2002 to 28.6 in 2011.[5]

6) Injury-related disabilities affect an estimated 3.5 million people in India; among these, about 2 million are caused by road traffic accidents.[6]

7) Untrained and unskilled personnel provide most of the pre-hospital care. Only 4% of the ambulance workers have certified training.[7]

8) District and village hospitals are usually unable to deal with patients with complex trauma or multiple injuries.[8]

“All Indians deserve medical relief irrespective of their social, religious or economical background especially in accidents and emergencies.”

With this in mind and no “real” effort from various authorities, I have mustered support to start trauma centers along this highway. The first of which is being constructed at Kambla which is 6 kilometers from Mahad (a site fraught with many accidents) (Picture 3). Coincidently, this spot is less than 2 Kms from the Savitri river bridge which collapsed killing over 40 people. The aim of this project is to set up small, but useful and powerful “Trauma Units” to look after accident victims along the National Highways. The one at Mahad (Kambla) being the pilot unit. We have received local support from the Konkan Rural Development Charitable Association (Kazi and Mukadam families who reside in the area) who are funding the building costs, the Anjuman Dardmandane Talim-O-Tarakki who have provided the land and have a wide local network; they also run a school and were instrumental in providing free food and shelter to the relatives of all the victims in the recent Savitri bridge catastrophe, and lastly The Shaukat C. Chagla Memorial Trust which will further help in funding the center and manage the actual working of the center. We already have two ambulances in place (Picture 4); one doctor is already running an outpatient clinic, who will be trained in Emergency Services and we shall hire the services of another doctor who will also be housed in the complex. We will need to get the paramedical staff and other people who will work as helpers in the unit. The center with have an intensivist or an anesthetist trained in intensive care to manage the critical cases and stabilize victims till they can be transferred to tertiary care centers. We will have a minor operation theater to take care of some of the life threatening emergencies that may need surgery, routine suturing of small lacerations, and reduction of fractures will be possible as well. Though the project seems vast and difficult, with the resources available we plan to keep things simple and cost effective. This is quite a doable project and many people from different regions on NH 17 (66) have come forward requesting us to help set up similar centers.

In conclusion, the aim of these centers is to manage and resuscitate accident victims, provide the initial treatment, and document the clinical status of the patient which is so critical in the ultimate outcome of the patient. The idea of a small but powerful unit is to be able to treat the victim in the GOLDEN hour, a concept which believes that many lives can be saved if the patient arrives at dedicated trauma centers within the hour of the accident.[9]

TC- Oct 2016 - 002 - Writers Art pg 07

Acknowledgements :

I would like to thank in particular, Dr. Mayur Bhanarkar, a final year student at the Seth G.S. Medical College, Mumbai for putting together some of the data for this editorial.

TC- Oct 2016 - 003 - A collision between two state transport buses TC- Oct 2016 - 004 - The British-built bridge over the Savitri river TC- Oct 2016 - 005 - The Building site of the Trauma center TC- Oct 2016 - 006 - The Ambulance donated by the Konkan Rural Development Charitable Association

 

References:

  1. Gupta A, Gupta E. Challenges in organizing trauma care systems in India. Indian J Community Med. 2009;34:75–76. doi: 10.4103/0970-0218.45383. [PubMed]
  2. World Health Organization. Metrics: disability-adjusted life year (DALY). Available at: http://www.who.int/healthinfo/global_burden_disease/metrics_daly/en/. Accessed January 3, 2013. [Ref list]
  3. a) Ministry of Road Transport and Highways. Basic road statistics of India 2008–09, 2009–10, and 2010–11. Available at: http://morth.nic.in. Accessed August 31, 2012. [Ref list]
    b) Ministry of Road Transport and Highways. Road transport year book (2009–10 and 2010–11). Available at http://morth.nic.in. Accessed August 29, 2012. [Ref list]
  4. Joshipura MK, Shah HS, Patel PR, Divatia PA, Desai PM. Trauma care systems in India. Injury. 2003; 34:686–692. doi: 10.1016/S0020-1383(03)00163-3.[PubMed]
  5. Ministry of Road Transport and Highways. Road accidents in India 2011. Available at: http://morth.nic.in. Accessed August 31, 2012. [Ref list]
  6. Gururaj G. Road traffic deaths, injuries and disabilities in India: current scenario. Natl Med J India. 2008; 21:14–20. [PubMed]
  7. Joshipura MK, Shah HS, Patel PR, Divatia PA, Desai PM. Trauma care systems in India. Injury. 2003; 34:686–692. doi: 10.1016/S0020-1383(03)00163-3.[PubMed]
  8. Joshipura MK. Trauma care in India: current scenario. World J Surg.2008; 32:1613–1617. doi: 10.1007/s00268-008-96345. [PubMed]
  9. Edlich RF, Wish JR. Maryland State Police Aviation Division. A model emergency medical system for our nation J Long Term Eff Med Implants. 2004;14(5):401-14