Trauma Care in Low- and Middle-Income Countries

Background Trauma-related injury causes higher mortality than a combination of prevalent infectious diseases. Mortality secondary to trauma is higher in low- and middle-income countries (LMICs) than high-income countries. This review outlines common issues, and potential solutions for those issues, identified in trauma care in LMICs that contribute to poorer outcomes.

Methods A literature search was performed on PubMed and Google Scholar using the search terms “trauma,” “injuries,” and “developing countries.” Articles conducted in a trauma setting in low-income countries (according to the World Bank classification) that discussed problems with management of trauma or consolidated treatment and educational solutions regarding trauma care were included.

Results Forty-five studies were included. The problem areas broadly identified with trauma care in LMICs were infrastructure, education, and operational measures. We provided some solutions to these areas including algorithm-driven patient management and use of technology that can be adopted in LMICs.

Conclusion Sustainable methods for the provision of trauma care are essential in LMICs. Improvements in infrastructure and education and training would produce a more robust health care system and likely a reduction in mortality in trauma-related injuries.

Tracking global development assistance for trauma care: A call for advocacy and action

Background: This study aimed to track development assistance for trauma care (DAH-TC), uncover funding trends and gaps, and compare DAH-TC to development assistance for other health conditions.

Methods: A systematic search of the OECD Creditor Reporting System (CRS) and Development Assistance Committee (DAC) databases was performed to capture projects related to trauma care. Reports from large foundations and public-private partnerships were also searched. DAH-TC was described, and comparisons were made between DAH-TC and other health conditions.

Results: The search yielded 1754 records; after applying exclusion criteria, 301 records were included for analysis. During the 25-year period, US$93.7M of DAH-TC was disbursed to low- and middle-income countries (LMICs) (0.02% of total DAH). Contributions were dominated by a few donors and fluctuated dramatically over time. A sizable portion of DAH-TC came in the form of investments to build infrastructure (38% of DAH-TC); information and research activities (17%); and training (16%). Nearly US$58M (62% of DAH-TC) was funneled to projects that targeted victims of war. Trauma care received US$0.04 per DALY incurred, while malaria, TB, HIV and MCH received US$9.62 per DALY, US$25.09 per DALY, US$4.05 per DALY and US$45.75 per DALY, respectively.

Conclusions: DAH-TC is critically underfunded, particularly compared to other health foci. To improve the DAH-TC landscape, stakeholders can better mobilize domestic resources; use advocacy more effectively by catalyzing network convergence, grafting trauma care onto related high-priority issues, and seeking broader coalitions; and develop partners within the donor and channel communities to promote strategic DAH-TC disbursements.

Perception and Attitude of Surgical Trainees in Nigeria to Trauma Care

Background. Trauma is still the leading cause of death in individuals between the ages of 1 and 44 years. Establishment of good trauma centres and systems has been shown to have a significant positive impact on outcomes. Surgical specialties, particularly trauma, are becoming less attractive in different parts of the world for a variety of reasons. Aim.  The aim of this study is to ascertain the perception and attitude of future surgeons towards trauma care in Nigeria. Materials and methods. This is a cross-sectional study using a pretested, structured, paper-based questionnaire which was administered to consecutive surgical trainees at the annual revision course of West African College of Surgeons. Data were analyzed using SPSS version 12, and results are presented in tables and figures. Results. One hundred and fifty-seven questionnaires were adequately completed with a male-to-female ratio of 18 : 1 and median age of 30 years. There is a general agreement among the respondents that trauma incidence in Nigeria is high or very high. While about 70% of the respondents believe that the Nigerian trauma system is poorly planned, about 19% think it is nonexistent. 81 (53.7%) agree or strongly agree that managing trauma patients is too stressful. A good number, 116 (74.4%), strongly agree that having a separate dedicated trauma unit will improve care and outcome. While 82% of the surgical trainees support post fellowship training in trauma, only 62.2% will like to have the training. There is no significant difference between the proportion of males and females who would like to have the training. Conclusion. Surgical trainees in Nigeria have good perception and positive attitude towards trauma care. Primary prevention measures must be emphasized during surgical trainees’ training in trauma.

Designing and implementing a practical prehospital emergency trauma care curriculum for lay first responders in Guatemala

Background Injury disproportionately affects low-income and middle-income countries, yet robust emergency medical services are often lacking to effectively address the prehospital injury burden. A half-day prehospital emergency trauma care curriculum was designed for first responders and piloted in the Sacatepéquez, Chimaltenango, and Escuintla departments in Guatemala.

Methods Three hundred and fifty-four law enforcement personnel, firefighters, and civilians volunteered to participate in a 5-hour emergency care course teaching scene safety, triage, airway management, cardiopulmonary resuscitation, fracture management, and victim transport. A validated 26-question pretest/post-test study instrument was contextually adapted and used to measure overall test performance, the primary study outcome, as well as test performance stratified by occupation, the secondary study outcome. Pretest/post-test score distributions were compared using a Wilcoxon signed-rank test. For test evaluation, knowledge acquisition on a by-question and by-category basis was examined using McNemar’s χ² test, whereas item difficulty indices used frequency-of-distribution tests and item discrimination indices used point biserial correlation.

Results Two hundred and eighty-seven participants qualified for inclusion. Participant mean pretest versus post-test scores improved 24 percentage points after course completion (43% vs 68%, p<0.001). Cronbach’s alpha yielded values of 0.86 (pretest) and 0.94 (post-test), suggesting testing instrument reliability. Between-group analyses demonstrated law enforcement and civilian participants improved more than firefighters (p<0.001). Performance on 23 of 26 questions improved significantly. All test questions except one showed an increase in their PPDI.

Discussion A 1-day, contextually adapted, 5-hour course targeting laypeople demonstrates significant improvements in emergency care knowledge. Future investigations of similar curricula should be trialed in alternate low-resource settings with increased civilian participation to evaluate efficacy and replicability as adequate substitutes for longer courses. This study suggests future courses teaching emergency care for lay first responders may be reduced to 5 hours duration.

Level of evidence Level II.

Musculoskeletal trauma services in Mozambique and Sri Lanka.

There is currently an escalating epidemic of trauma-related injuries due to road traffic accidents and armed conflicts. This trauma occurs predominantly in rural areas where most of the population lives. Major ways to combat this epidemic include prevention programs, improved healthcare facilities, and training of competent providers. Mozambique and Sri Lanka have many common features including size, economic system, and healthcare structure but have significant differences in their medical education systems. With six medical schools, Sri Lanka graduates 1000 new physicians per year while Mozambique graduates less than 50 from their singular school. To supplement the low number of physicians, a training course for surgical technicians has been implemented. Examination of district hospital staffing and the medical education in these two countries might provide for improving trauma care competence in other developing countries. Musculoskeletal education is underrepresented in most medical school curricula around the world. District hospitals in developing countries are commonly staffed by recently graduated general medical officers, whose last formal education was in medical school. There is an opportunity to improve the quality of trauma care at the district hospital level by addressing the musculoskeletal curriculum content in medical schools.