| Abstract|| |
Background: The three pillars of a good trauma system are the prehospital care, definitive care, and rehabilitative services. The prehospital care is a critical component of the efforts to lower trauma mortality. Objective: To study the prehospital profile of patients who died due to trauma, compute the time taken to reach our facility, find the cause of delay, and make feasible recommendations. Materials and Methods: A hospital-based study was performed at a trauma center in Puducherry from June 2009 to August 2010. Puducherry is a union territory of India in the geographical terrain of the state of Tamil Nadu. A total of 241deaths due to trauma were included. Apart from the demographic and injury characteristics, a detailed prehospital log was constructed regarding the time of incident, the referral patterns, care given in the prehospital phase, the distance travelled, and the total time taken to reach our center. Results: The majority (59%) of patients were referred, with stopovers at two consecutive referral centers (30%), needing at least two vehicles to transport to definitive care (70%), clocking unnecessary distances (67%), and delayed due to non therapeutic intervention (87%). The majority of deaths (66%) were due to head injury. Only 2.96% of referred cases reached us within the first hour. Few of the patients coming directly to us had vehicle change due to local availability and lack of knowledge of predestined definitive care facility. Overall, 94.6% of direct cases arrived within 4 h whereas 93.3% of referred cases required up to 7 h to arrive at definitive care. Conclusions: Seriously injured patients lose valuable prehospital time because there is no direction regarding destination and interfacility transfer, a lack of seamless transport, and no concept of initial trauma care. The lack of direction is compounded in geographical areas that are situated at the border of political jurisdictions.
Keywords: Prehospital care, prehospital time, referrals, trauma death
|How to cite this article:|
Radjou AN, Mahajan P, Baliga DK. Where do I go? A trauma victim's plea in an informal trauma system. J Emerg Trauma Shock 2013;6:164-70
| Introduction|| |
Trauma remains a leading cause of death worldwide taking a maximum toll on middle and lower income countries. There is a rise of 3% in road traffic accidents (RTA) in India.  Trauma systems are designed to centralize various resources to efficiently assure complete access to definitive care. A mature trauma system is one where all the three components; prehospital, definitive care, and rehabilitation are being strengthened constantly.
The trauma system in India has a long way to go.  Seriously injured patients in India are six times more likely to die compared to countries with well matured trauma systems  where early referral to definitive care results in better  and delays in poor outcomes. 
Prehospital care, the process that gets the right patient, to the right facility, at the right time, is the weakest and most difficult link in the chain of survival due to diverse interplay of factors involved. India has published a very little on trauma  with even sparser literature on the exact prehospital scenario, an important tenet of a trauma system, highlighting the urgent need for research in these settings. Puducherry is a union territory on the east coast of South India. It is a conglomerate of areas interspersed in the geographical terrain of Tamil Nadu (TN), which is a separate state. Puducherry has the highest accident rate of 88.1 per 100,000 population against the national average of 30.5 National Crime Records Bureau (NCRB).  The Government General Hospital, which was designated as a trauma center by the Government of India in 2000, has a census of 1500 seriously injured patients per year from Pondicherry and the neighboring districts of TN which are also areas of high trauma rates (44.5). Our hospital has noted a steady increase in frequency of trauma patients referred after initial encounters at hospitals of various designations within a 150 km radius. We decided to examine the degree of incoordination in the prehospital part of the chain with the objective to propose improvements to the system in this region.
| Materials and Methods|| |
This is a prospective descriptive study from 1 June 2009 to 31 August 2010 (15 months). The prehospital log of 241 trauma fatalities was gleaned from hospital records; and additional information obtained from the patients, their relatives, accompanying police or ambulance crews, and the postmortem records.
The main data collection was undertaken by the principal investigator (AR) and was assisted by colleagues and nursing staff. Interviewer-administered questionnaires as well as hospital records were used by the investigators to gather information on various demographic characteristics of the victim such as place, month and time of injury, mechanism, whether admitted directly or referred, type of facility first consulted, number of referrals before admission to the study center, type of care received at referral centers, number of vehicle changes/transfers and unnecessary distances clocked (where applicable), total distance travelled, and the total time taken to reach definitive care.
Study permission was granted by the Medical Superintendent of the Indira Gandhi Government General Hospital, Puducherry and the Director of Medical Services, Government of Puducherry. We had adhered to ethical principles while gathering the information. Confidentiality of the subjects was maintained in the Department of General Surgery.
No formal sample size was calculated. All fatally injured patients whose prehospital log was complete were included. Data were analyzed using means and proportions.
| Results|| |
A total of 7851 trauma cases (minor, moderate, serious, and fatal) were treated during the study period. Complete prehospital data were available for 241 fatally injured patients. RTA was responsible for 83%. The majority were males (211 males, 88%) between 25 and 65 years of age, pedestrians and cyclists (42.32%), and motorcyclists (31.54%). Most cases (37%) had sustained injuries over the weekends and between 4 pm and 12 midnight (48%) [Table 1]. The majority (56%) were referred while 44% of cases reached our center directly from the scene of injury. Most of these referrals were from the District/Taluk headquarter hospitals of the adjoining state (87%), while 13% were transferred from tertiary centers [Table 2].
Regarding the prehospital profile, we had divided the cases into direct group (D) and referred group (R). The direct group had traveled a mean distance of 31.4 km taking 90 min to reach us while the referred group had travelled a mean distance of 52.81 km, but taken 279 min to reach us [Figure 1] and [Figure 2]. Fifty-four percent of referred cases had clocked unnecessary extra distance (median 24.49 km) to reach definitive care compared to 10.86 km by 14. 2% of the direct cases [Table 3]. One-third of referred cases had been seen in two facilities before reaching us [Figure 3]. Seventy percent of referred cases needed more than two sets of vehicles to reach us [Table 3]. Only 8% of these fatally injured patients had either primary survey or partial appropriate treatment at the referral centers [Figure 4].
|Figure 3: Number of encounters at medical facilities before reaching definitive care|
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| Discussion|| |
Trauma and especially RTAs are the invariable fall out in the rapid motorization and industrialization in India. Disparity in prehospital emergency care services around the world runs the gamut from no organized system, providing transportation only, stabilizing with basic care and transport, to use of mobile intensive care. The importance of a systematic prehospital triage and effective transfer processes has been highlighted in numerous studies by Mullins as early as 1996  and stands validated a decade later, by Harrington et al. 
Road traffic incidents were responsible for 83% of trauma fatality, higher than the 46% in a Mumbai study, where rail accidents were up to 25%, as rail travel is a very popular means of transport in the city of Mumbai.  The majority were males (88%) in the age group 25-45, mostly pedestrians (36.54%), followed by two wheelers (31.54%) which is in keeping with the trend in developing world  . Peak times were 8-12 h (21%) and 16-20 h (26%), comparable to NCRB data  with a sharp fall from 24 to 4 h (6%) similar to a study from Bengaluru  and contrary to popular belief [Figure 1]. About 36% of fatal incidents took place at the weekend comparable to National Crime Records Bureau Report in 2009.The day and time of accidents is of relevance in any prehospital profile analysis. This emerging trend can help in planning to mobilize resources regarding ambulance response, personnel, and seamless interfacility transfer. The first port of call was a government facility in 88% of our cases similar to 82.6% in Mumbai which also has a high accident rate of 55.1  and other developing countries like Brazil  but in contrast to 40% in Bengaluru. 
The majority (56%) were referred cases. Forty-four percent of cases reached us directly from the scene of injury in contrast to 28.2% in Bengaluru  and 66% in the Ontario province of Canada.  The majority (87.40%) were from District headquarter/Taluk hospitals from the neighboring state, far higher than the 40.1% reported from Bengaluru.  These referral centers do handle general surgery emergencies, but do not have the expertise to deal with major trauma similar to the situation in a developing country such as South Africa.  A significant proportion (12.6%) came from private tertiary centers/private medical colleges in Puducherry and Tamil Nadu, in contrast to 5% in the study from Bengaluru.  Hesitation to deal with major trauma stems from attempts to avoid deaths in their facility  . Inability to pay as in Bengaluru,  Mumbai,  and USA  are common non medical factors involved in trauma transfer. Over the years, there has been an increase in informal transfer of trauma patients to our center. It is accepted that government establishments will invariably bear the brunt of trauma  and hence it is important to strengthen trauma services which obviously includes the prehospital transportation and triage issues.
The mean distance traveled by direct cases was 31.44 km (range 5-320 km). While the majority (47%) had to travel 50 km and 0.8% had to travel more than 300 km in contrast to 20% and 5% in Mumbai.  Above 20 km, there was a tendency to stopover at a medical facility [Figure 1]. However, a significant proportion of patients (50%), who had clocked 50 km, came to us directly without a stopover as they were at or near national highways, and access to our center was presumed to be faster and easier. Hence transportation times itself rather than distance per se, can be used for triage to trauma centers. Regions in developed countries where there is no centralized trauma care have adopted transportation time limits of <20 min to triage to trauma centers.  Analyzing the geographical distribution of RTA occurrence and the distance between injury scenes and the trauma center can provide useful information in planning EMS systems, particularly new ambulance dispatch centers or trauma centers. However, distance by itself is not the only factor for adverse outcome. The time taken to reach definitive care and the quality of care during transport are equally important.  It is unfortunate that 92% of patients in our study had no primary survey at the referral centers comparable to 88% reported by Singh et al.,  85% in Chennai,  and 50% in the Mumbai study.  The majority (92%) had various combinations of documentation detailing external wounds, X-rays of skull, antibiotics and suturing of nonbleeding wounds, and tetanus toxoid [Figure 4]. Hence the delay was due to non therapeutic issues in these fatally injured patients. The first medical encounter is decided by the patient or bystanders present at scene and the choice invariably falls on the nearest medical facility which often would be ill equipped with resources to treat major trauma. The word "first aid" and stabilization have different meaning among the judiciary, lay people, and even non trauma doctors. Neither Indian law, nor the orders of the Supreme Court and various High Courts of India have defined an emergency. The definition of an emergency is still largely left to the discretion of medical professionals.  The medical personnel themselves who are not aware of principles of acute trauma care, treat what the public thinks, and demands as "first aid" (tetanus toxoid, dressing, suturing, etc.) which is by no means lifesaving in the fatally injured. However, this issue is not unique to our part of the world as even in developing trauma systems patients spent an average of 2.5 to 4 h in the ED of a non trauma center before transfer. , Performing X-ray skull was another cause for delay. Only 36% of serious head injuries had fracture skull in our study. Unnecessary imaging for medico legal purposes is the most common cause of delay.  Training in advanced trauma life support (ATLS) has reduced this apprehension. 
Trauma knowledge is grossly inadequate in India,  even at senior levels,  and this is also reported in other developing nations like Brazil.  Institution of ATLS guidelines and mandatory ATLS training does improve trauma outcomes.  In India, short courses do help in theory;  however, it has been noticed that in spite of assumed knowledge of ATLS and presumed awareness of the ABC concept, there was gross deficiency (83%) in final trauma care,  calling for skill maintenance.  We noted more emphasis given to descriptions of external wounds than on the ABCDE of trauma in most medicolegal documentation. Hence physicians with no training in trauma would be keener on conforming to the conventional proforma, side stepping ABCDE. coupled with the tendency to avoid medicolegal hassles  and thus refer patients to nearby government hospitals.  It therefore follows that medicolegal practices need to be made more simple and scientific.
One referral before trauma center admission is the minimum need, but it is disheartening that 30% of our referred cases had been to two facilities before reaching us, compared to 4.7% reported in a multicenter study where the buck stopped at study centers.  Upendra et al. reported a transfer rate of 3.4 per person in spinal trauma in India.  Multiple transfers do lead to increased mortality and morbidity. , Patients in our study were referred to multiple facilities without any idea about what the patient needs and what that facility could offer. This second stopover results in further nontherapeutic testing, repeat documentation, arranging of transport for further referral, change of vehicles, and so on.Without direction regarding definitive care, providing prompt emergency transport is only a Brownian movement More Details for the end user, the patient. Integration of the trauma care system has to be tighter at borders of political jurisdictions, to comply with legal direction as laid down by the Supreme Court. 
Seventy percent of referred cases needed a second vehicle for transport [Table 3]. The first vehicle crew takes the patient to the first health facility, and leave immediately without waiting to find out if the patient would be referred to a second facility. Hence the need to call for another vehicle, leading to further delay similar to immature trauma systems in developed countries.  Only two patients (0.82%) were transferred to us with prior discussion. Lack of interhospital transfer protocols has been reported by Isaksen et al.  We did not find any undue referrals likely during lean staffing periods in referring centers in contrast to studies by Koval et al.  and Roy et al. 
Due to complete lack of direction and predetermined destination protocols, it was realized that patients were moving away from our definitive care, looking for the nearest facility, with subsequent referral from there to another non definitive care and finally transferring to the trauma center. This is more pronounced in the referred group who had to clock extra distances from 10 to 60 km distances either because they had moved away from our center, or were referred to another facility via a tangential route, to finally reach us. In the direct group, a small but definite proportion of 14.5% had clocked unnecessary distances of 10-40 km as the public and ambulance crew were not aware of trauma care facilities [Figure 5]. To the best of our efforts, we could not find studies looking at this part of prehospital profile. In India, proper coordination between the trauma receiving facility and ambulance services is present in as low as 4% of the prehospital networks. 
|Figure 5: Distance inadvertently traveled away from our trauma centre looking for care before eventually coming to us|
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Overall, the mean time to reach definitive was 209 min care, compared to 72 h as reported by Singh et al.  who reported isolated spinal injuries. Only 45.5% of the direct admission group and a dismal 2.96% of referred group could reach us within the first hour of trauma care [Figure 2]. In summary, the direct group had traveled a mean distance of 31.4 km taking 90 min to reach us in contrast to the referred group that had taken 279 min to travel 51.81 km similar when compared to 83 min and 150 min reported in Haryana  and far greater than the 59 min and 270 min in Perth.  The undue delay in the referred group was due to the multiple referrals and unnecessary distances traveled due to lack of triage and transfer protocols. This chaos in prehospital care is expected as no national or regional guidelines exist for triage, patient-delivery decisions, prehospital treatment plans, and inter hospital transfer protocol in India  and other developing countries like Pakistan.  Unfortunately, development of prehospital and institutional trauma care does not always grow in a coordinated manner.  The problems in India of triage,  lack of responsibility, and maldistribution of skill  negate the sole emphasis on rapid transport to the nearest medical facility. Due attention to definitive trauma care should be inclusive  to involve upgrading of the referral hospitals, as most trauma can be managed by general surgeons in secondary level facilities on clinical grounds. 
Prehospital services need to be coordinated so that the right patient is taken to the right hospital in the right time. This calls for a lead agency at the district, state, and finally at the national level. Steps have been taken in the state of Gujarat  and at the national level.  Regionalization of trauma care and attempts at inclusive trauma care rather than stand alone trauma centers, which may not be economically viable with our resources, are essential. Head injury was the commonest cause of death at 66%, and this finding would be of help in developing outreach programs for trauma care in referral hospitals. Any prehospital system, however narrowly defined, will be called upon to respond to all sorts of emergency. When these prehospital care systems are linked to a regional public health system, they can substantially enhance access to care for a wide range of emergencies, identify opportunities for improvement and strengthen a country's overall disaster response capacity.
In conclusion, the process whereby trauma patients arrive at our center is unsafe. Hence the designated trauma center should take the lead responsibility, in the search for solutions and implementation, relevant to local regions with a high trauma rate.
We recommend the following for our catchment area of 150 km:
Strength of the study
- Optimal distribution of available skills
- Trauma care has to be regionalized and inclusive with tighter integration across the two political jurisdictions. This will entail triage guidelines, predetermined destination protocols, upgrading of referral centers, and targeted outreach programs to upgrade skills
- Public awareness must be improved
- Medico legal practices should be simplified
- Strengthen definitive care across the entire region
- Establish education, training, and skill maintenance
- Encourage research.
This study was undertaken in a state public hospital that has a large trauma load. We believe that our study is the first in India to log the entire prehospital time of fatal injuries. An attempt was made to analyze each dimension that can lead to strategically chosen initiatives for improvement. The descriptive characteristics may be employed in the development of triage protocols and transfer guidelines, and initiate an inclusive trauma system across political borders.
Limitations of the study
This is a single center study. There is always a probability of Berkson's bias and external validity of the outcome of study is limited as this was a hospital-based study with our limited resources. The distance was calculated approximately, by conventional estimates and at times taken as a straight line. Hence, the actual distance traveled may be much greater. Time taken to travel the same distance during peak traffic times will be even longer. Even if the accident happened during the quiet period, the patient may be traveling during peak hours to reach our facility. Only fatal cases were included as completion of the log was available during post mortem, where the police and relatives were available en masse and thus could provide missing data.
| Future Directions of Study|| |
This study addresses one prehospital aspect in rapidly urbanizing areas in India. In most of the places in India, prehospital care is just providing ambulances. Further studies of this nature would be able to initiate focus by the stakeholders, on the more important structural part of prehospital care. Future linking of data from nontrauma center acute care hospitals would help in exactly pinpointing the correctable flaws in the prehospital system in this part of the country. Therefore, further studies based on the results and recommendations from this pilot study are advocated.
| Acknowledgement|| |
We acknowledge contributions of Dr. R Balaraman Head, Department of Forensic Medicine and Dr. S Diwakar, Specialist, Department of Forensic Medicine, Indira Gandhi Government Hospital and Postgraduate institute, Puducherry, in our study.
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Angeline N Radjou
Department of Surgery, Indira Gandhi Medical College and Research Institute, Puducherry
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3]