The Burden of Trauma

With rapid increase in Traumatic Brain Injuries (TBI), India faces the major challenges of prevention, pre-hospital care and rehabilitation needs of brain injured persons. The government needs to put in place a clearly defined road safety policy, a central coordinating agency, allocation of adequate resources, and strict implementation of proven and effective interventions to reduce trauma-related mortality and morbidity …
By Amresh K Tiwary

Trauma can be defined as an injury to living tissue caused by an extrinsic agent, examples include the consequences of motor vehicle accidents, falls, gunshots, physical assaults or other forms of trauma. Road traffic injuries are the leading cause of Traumatic Brain Injuries (TBIs), followed by falls and violence.
Concerted efforts are required for effective and sustainable prevention and management of such injuries in India. One of the essential needs is to establish the trauma registries to monitor the system and provide state-wide cost and epidemiological statistics.
TBI is increasingly being recognized as a public health problem of immense proportions with the substantial burden of disability and death occurring in low and middle income countries (LMICs). In high income countries, the incidence of TBI due to road traffic incidents has decreased following the successful implementation of preventive measures (legislations, safer roadway infrastructure, car safety measures and helmets); nevertheless, the burden of TBI in these countries remains high due to an increasing number of elderly patients with TBI due to a fall. Road traffic accidents remain the main cause of TBI in LMICs.
Approximately 90% of the world’s road fatalities occur in the setting of LMICs, although they only have half of the worlds’ vehicles. International awareness that action is necessary, is increasing: The United Nations Decade of Action for Road Safety aims to reduce to half, the 1.3 million traffic-related deaths each year by 2020 through various measures including road safety management, safer vehicles, better informed road users and an improved post-crash response (World Health Organization).
The trauma surgeons believe that 20.5 per cent of the trauma patients die in phase III (within 24 hours to 7 days) due to respiratory failure or as a result of post-traumatic complications. A substantial proportion of patients (51.61 percent) who survive for more than one week (phase IV), later die as a result of secondary complications like sepsis or multiple organ system failure. The respiratory insufficiency and related complications are the most common causes of morbidity and mortality in acute spinal cord injuries (SCI) with an incidence of 36 to 83 per cent. The ventilator failure may last up to an average of five weeks causing delayed deaths in these cases. Therefore, an effort must be taken up to improve respiratory function and minimise respiratory complications arising in serious traumatic cases.

Road Accidents: Leading Cause of Trauma
The World Report on Road Traffic Injury Prevention indicates that by 2020, road traffic injuries will be a major killer accounting for half a million deaths and 15 million disability adjusted life years. Evidence supports the fact that timely referral to trauma centres, equipped with proper facilities to deal with serious injuries, results in reduction of mortality among victims.
Active nightlife like clubs and pubs, reluctance to use helmets, seat belts, violation of speed limits, lack of tolerance, and increasing competition are some of the causes of increasing road traffic accidents.
According to a report, a vehicular accident occurs every three minutes, and trauma-related death occurs every 1.9 minutes. In this context, accurate mortality statistics are important for implementing appropriate prevention strategies, improving emergency preparedness, instituting financing policies and appropriate health packages.
The latest report of National Crime Records Bureau says that the total number of deaths every year due to road accidents has now crossed the 135,000 mark. While trucks and two-wheelers are responsible for over 40 per cent of deaths, peak traffic during the morning and evening rush hours is the most dangerous time to be on the roads. The situation is compounded by the menace of drunken driving. Liquor is a state subject and it is taking its toll everywhere in the country, not just Mumbai, Delhi, Bangalore, Hyderabad and metro towns. Ineffective laws, inadequate judicial procedure, little enforcement by the police, no specific segment where they can book people under drunk driving are making it difficult to check accidents under the influence of alcohol.
The road deaths are more rampant in developed states like Andhra Pradesh, Maharashtra and Tamil Nadu. Road safety experts believe that the real numbers of fatalities could be much higher since many cases are not even reported. There is no estimate as to how many people injured in road accidents die a few hours or days after the accident.

Head and Spinal Injuries Produce Trauma
Head injury is much more common in young adults than in the elderly. Trauma is the leading cause of death in people under the age of 40.The main causes of head injury are falls, motor vehicle accidents, and assaults.
According to experts, TBI to the head can lead to several types of injuries, including skull fractures, concussions, and cerebral contusions, diffuse axonal injury, epidural hematomas, and subdural hematomas and intracerebral hematomas. The skull fractures result from a significant blow to the head and can be associated with any of the above listed injuries. Concussion refers to a relatively minor injury, causing a relatively brief loss of consciousness. Cerebral contusions are brain bruises which occur from acceleration and de-acceleration of the head. Head trauma can also produce microscopic changes that are scattered throughout the brain. This category of injury is called diffuse axonal injury (DAI) and refers to the microscopic severing of axons (fibers which allow brain neurons to communicate with each other). If enough axons are injured in this way, then the ability of nerve cells to integrate and function may be lost or greatly impaired.
Dr Munish Aggarwal, Senior Neuro Surgeon, Shree Balaji Action Medical Institute, New Delhi, says, “Most of the early deaths (almost one-fourth of all) are in patients who sustain polytrauma along with spinal injury. There is a need to set up more specialised spinal and brain trauma units across the country with good accessibility to poorer sections of society for comprehensive management of spinal cord injured patients. Early liaison of hospitals without specialised spinal and brain units to specialised spinal centres should be encouraged, so that early presentation of acute spinal cord injured patient to a specialised spinal unit leading to early total care and reduction of mortality can be carried out successfully.”
There is a need to increase tertiary trauma care units with multidisciplinary approach for comprehensive care of critically injured patients. Steps must also be taken to improve injury surveillance and the quality of data collected. Detailed, complete and relevant data will guide prevention efforts aimed at risk factors in the individual and the environment and provide feedback to trauma care providers. Further monitoring of these trends will influence training, improve the focus of the trauma service and direct the provision of more effective care to these severely injured patients. These findings also suggest the need to allocate resources for trauma prevention, and promote research towards improving the care of acutely injured patients.

Says Dr Amit Gupta of Dr Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, “Proper coordination between the trauma receiving facility and ambulance services is present in as low as 4 per cent of the pre-hospital network. It has been shown that minimising pre-hospital time greatly helps in reducing trauma-related mortality and morbidity. The spot deaths have markedly declined by introducing the special mobile ambulance services to accident patients.”
Concurs Dr Amit Gupta, “It has also been observed that attendants accompanying patients having cervical spine or head injury have little knowledge regarding precautions to be taken to prevent further neurological deterioration during transportation. The place of first medical encounter is decided more often by the relatives, bystanders, and police. In this chaos, the patient is taken to the closest medical facility, which may be grossly inadequate to deal with serious trauma. The golden hour is thus spent without appropriate resuscitation. Expeditious and careful transport of patients with acute cervical spine or spinal cord injuries should be carried out from the site of injury by the most appropriate mode of transportation available to the nearest capable definitive care medical facility.”

Minimising Pre-Hospital Time Helps in Reducing Trauma
According to a study conducted at a level I trauma centres like Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, about 3500 patients are admitted every year with no assigned trauma catchment area or geographic jurisdiction. Retrospective data were collected from CPRS (computerised patient record system) of this hospital and autopsy reports maintained in the department of Forensic Medicine. All the cases/autopsy reports with spinal injuries whether in isolation or as a part of polytrauma were reviewed.

Well-Equipped Trauma Centres: Need of the Hour
Injuries are caused by a complex interaction among agent (vehicle, product), human and environmental factors operating in complex sociopolitical and economic systems. Injury prevention and control depending on evidence-based research is gaining momentum all over the world. High-income countries have made significant progress in the past two–three decades by developing comprehensive, integrated and intersectoral approaches based on scientific understanding. This has resulted in a decline in death and disability due to injuries. Accident and trauma care services were identified as an important area for growth and development during the Tenth Plan period. The report acknowledges that ‘there are no organised comprehensive trauma care services either at the Centre or State level.’ It specifies that ‘services developed in the past have not been linked to an effective multidisciplinary trauma care system’. The report further highlights the need for emphasis to be laid on adequate training of medical and paramedical personnel, provision of facilities for transport of patients, suitable strengthening of existing emergency and casualty services, and improving referral linkages. Both research and experience have proved that with existing resources, many activities can be performed at peripheral levels with adequate knowledge and skills. This implies that staff (medical/non-medical) requires training to perform these tasks with basic and refresher programmes. Availability of equipment means that these facilities are not only available but also functional, and can be put to use throughout a 24-hour period. Organisational support must be provided for skills enhancement, curative and partial rehabilitative services to trauma patients.
World Health Organization (WHO) in its first ever Global Status Report on Road Safety claims that speeding, drunk driving and low use of helmets, seat belts and child restraints in vehicles are the main contributing factors. Every hour, 40 people under the age of 25 die in road accidents around the globe. According to the WHO, this is the second most important cause of death among 5 to 29 year olds.

TBIs on the Rise in India
Comprehensive research in India in the area of TBIs is extremely limited. Scientific information in this area is vital and a basic prerequisite is to understand the enormity of the problem and its various determinants and various dimensions to formulate, implement and evaluate programs for reduction of morbidity, mortality, disability and socioeconomic losses in every country. Earlier research in India has been extremely limited and has been from isolated settings based on personal areas of interest by individual researchers.
The incidence of head injury is on the rise in India. The number of deaths and burden of disability may be reduced, if not completely stopped, through preventive measures after an epidemiological survey on trauma. The goal can be achieved to a significant extent through the use of guidelines from the countries that have achieved a reduction in the incidence of neurotrauma. To determine the incidence and outcome of neurotrauma in developing countries, a study was necessary using standardised assessment parameters for global interpretation.
Injuries and TBIs in India have been increasing significantly due to rapid motorisation, industrialisation, migration and changing value systems of Indian society. The consequences on health are tremendous and have been underestimated due to absence of research. Apart from instantaneous deaths, the suffering and poor quality of life among survivors is a living testimony to the impact of TBIs. It is estimated that nearly 1.5 to 2 million persons are injured and 1 million succumb to death every year in India. Road traffic injuries are the leading cause of TBIs followed by falls and violence. Alcohol involvement is known to be present among 15 -20 percent of TBIs at the time of injury. The rehabilitation needs of brain injured persons are significantly high and increasing from year to year.
Dr Sandip Jain, Trauma Surgeon, Max Super Speciality Hospital, Vaishali (Ghaziabad), says, “Trauma-care systems in India is at a nascent stage of development. Industrialised cities, rural towns and villages coexist, with almost complete lack of organised trauma care. There is gross disparity between trauma services available in various parts of the country. Rural India has inefficient services for trauma care, due to the varied topography, financial constraints and lack of appropriate health infrastructure. There is no national lead agency to co-ordinate various components of a trauma system. No mechanism for accreditation of trauma centres and professionals exists. Education in trauma life-support (TLS) skills has only recently become available. A nationwide survey encompassing various facilities has demonstrated significant deficiencies in current trauma systems.”
Although injury is a major public-health problem, the Government of India has failed to recognise it as a priority. Significant efforts to develop trauma-care systems across the country are seen mainly in the private sector. New initiatives under National Health Policy 2002 are expected to result in improvement in the systems, but the allocation of funds remains grossly inadequate for any significant impact on the outcome.
Says Dr H P Singh, Senior Consultant, Yashoda Superspeciality Hospital, Ghaziabad, “If we talk globally, it is important to mention that global annual cost of road traffic accident is 230 billion dollars, of which the share of developing countries is 65 billion dollars. This is double of total aid received for the national projects received. In India, more than 12.75 lakh people sustain serious injuries in road traffic accident and 1.2 lakh die every year.”
India has one percent of the world’s vehicles, but 6 percent of the total global road traffic accident deaths. Economic loss amounts to Rs 550 crore, an amount that equals our defense budget. Majority of road traffic accident injuries are of the nervous system, predominantly of the brain. In our country, 60 percent of TBIs are caused by road traffic accidents. Fatality rate is 70/1000 vehicles, which is 25 times higher than in developed countries.
The major cause of road traffic accidents are due to rash driving which usually happens during night. Intoxication by alcohol as a causative factor is seen in 15-20 percent traffic accidents. Reported incidence of mortality due to severe traumatic brain injury ranges from 38 to 43 per cent. Rehabilitation needs of severe head injury are 100 percent but there is a woeful lack of neuro-rehabilitation facilities.

Reducing Road Traffic Injuries
According to the latest data, there is more than 7.3 times increase in road accident injuries. As a result, a large number of individuals with TBI endure life-long impairment and disability. The sudden occurrence of brain injury places phenomenal burden on day-to-day activities, affecting survival and income.
It was estimated that the total costs of road traffic injuries alone is about 55,000 crore a year in India. Despite increase in TBI cases, there is lack of commensurate increase in research in TBI at all levels. The possible causes for lack of interest in research are lack of funding, lack of interest among neurosurgeons and others treating TBI, lack of time as there is skewed ratio of neurosurgeons to population.
The neurosurgeon takes more pride in demonstrating his surgical skills for removal of a complex skull base or vascular lesions, the incidence of which is very rare, but does not have interest in improving care of victims of TBI, the incidence of which is high.
Nearly 10-30 per cent of hospital registrations are due to road traffic injuries and a majority of these people have varying levels of disabilities. A majority of victims of road traffic injuries are men in the age group of 15-44 years and belong to the poorer sections of society. Also, a vast majority of those killed and injured are pedestrians, motorcyclists and pillions riders, and bicyclists. A clearly defined road safety policy, a central coordinating agency, allocation of adequate resources, strict implementation of proven and effective interventions and reliable information systems are urgently required. Greater participation from health and other sectors based on an integrated, intersectoral and coordinated approach is essential. Health professionals can contribute in numerous ways and should take a lead role in reducing the burden of road traffic injuries in India.