Car vs car.
Head-on collision.
Head on windscreen collision.
Headed to my local doctor.
He watched
and waited.
Hours.
Then
sent me to hospital.
But it was too late.
They said I had a traumatic brain injury.
Now I have nothing.
Trauma can be described as injury or damage to a biological organism due to physical harm from an external source [1]. Traumatic events are extremely common, causing 1 in 10 deaths worldwide, and making up 14% of the global burden of disease; this is expected to rise to 20% by 2020 according to the World Health Organisation (WHO)[1]. Road traffic accidents (RTA) contribute to a major proportion of these traumatic events [2]. They have a huge impact on both the individual, in the way of death, disability and financial costs, but also an impact on society in terms of economic loss, as it is often the working-age group involved in RTA [1, 3]. With an increase in urbanisation and motorisation, RTA are on the rise both in developed and developing countries.
Traumatic injury to the brain and spinal cord (neurotrauma) in particular can have significant consequences [3]. This is because direct injury to neuronal structures can lead to severe neurological debilitation. Even if death itself is not caused, the individual may be left with cognitive dysfunction (e.g. memory problems, depression, confusion, anger) or physical disability, rendering them dependent on others for the rest of their life. In some traumatic events, the injuries are catastrophic and therefore the consequences are unpreventable regardless of any medical or surgical treatment given. However in other cases, lives can be saved if the individual receives the appropriate management within the initial post-trauma golden hours.
So why do individuals not always receive this life-saving treatment on time?
Developed countries have protocols and systems in place, which allow trauma victims to receive the necessary medical attention in a timely manner. Unfortunately, this is not the case in many developing countries. In fact, a study comparing the outcome of traumatic brain injury (TBI) patients admitted to a hospital in the US and Jamaica, found that the patients had a significantly reduced risk of mortality if treated in the US hospital than those treated in the Jamaican hospital [4].
This discrepancy between developed and developing countries may be due to both a delay in care and the standard of care.
Delays in care begin from the point of the traumatic event. In developing countries, there may be an initial delay making contact with emergency services (if these are available in the region) or a delay in presenting to primary care health facilities (may be the only health resource in many areas). This means that initial basic resuscitation, such as immobilising the spine and securing the airway may not be achieved. Even if this first contact with medical services is made within an adequate timeframe, there is likely to be a further delay transferring the patient to a specialised neurosurgical centre. Hypoxia, hypotension and hypovolaemia are examples of avoidable causes of death due to delays [3].
Reasons for delay in presentation to specialised services are numerous. Firstly, there are infrastructural factors, such as a poor road network or lack of emergency services. Secondly, there may be a delay in decision for transfer from primary care services, due to the tendency to monitor neurosurgical patients for signs of possible recovery and instead treat the more visibly injured patients first (e.g. suturing lacerations). Thirdly, financial issues may affect the patient or family’s decision to seek specialised hospital treatment, as costs may be high [3].
The other reason for a discrepancy between developed and developing countries is the standard of care provision. In Africa, there are approximately 565 neurosurgeons in the entire continent; they are mainly concentrated in just a few countries in the continent, with some countries not even having one neurosurgeon [5]. With a shortage of resources and workforce together with rising rates of RTA, patients are having difficulty receiving the treatment they need.
This major issue is now being recognised and programs are beginning to be trialled to help improve surgical capacity. For example, Uganda has just 6 neurosurgeons for a population of 33 million. An initiative called The Duke Neurosurgery Program was therefore started a few years ago, with an aim to build neurosurgical capacity through technology, twinning and training [5].
Technology: focus on building the technological capability to perform neurosurgery. This involves providing safe anaesthesia, together with facilities for surgery and recovery (recovery room, theatre, ITU, general ward).
Twinning: develop a collaboration between a developed academic medical centre (Duke University Health System) and Uganda’s national hospital (Mulago Hospital), for funding and resources.
Training: develop a neurosurgical training program to train Ugandan surgeons in the specialty of neurosurgery.
There is now the hope of developing similar programs in other developing countries. For example, Madaktari Africa project in Tanzania is in the process of establishing its own program. Unfortunately government support is often minimal when trying to establish new programs, due to the already present high burden of communicable diseases in the country, lack of funds and hesitancy to support innovative projects which may or may not turn out to be successful. However the hope is that with initial support and funding from the developed country that is twinned with the program, these initiatives can at least be lifted off the ground. Once established, perhaps these governments will see the projects as a worthy investment to support, helping to change the country’s health infrastructure and improve the lives of those under their care.
References
Saatian M, Ahmadpoor J, Mohammadi Y, Mazloumi E. Epidemiology and Pattern of Traumatic Brain Injury in a Developing Country Regional Trauma Center. Bull Emerg Trauma. 2018;6(1):45–53. doi:10.29252/beat-060107
Adeleye AO, Ogun MI. Clinical Epidemiology of Head Injury from Road-Traffic Trauma in a Developing Country in the Current Era. Front Neurol. 2017;8:695. Published 2017 Dec 15. doi:10.3389/fneur.2017.00695
Malomo TA, Oyemolade TA, Adeleye AO. Determinants of Timing of Presentation of Neurotrauma Patients to a Neurosurgical Center in a Developing Country. J Neurosci Rural Pract. 2018;9(4):545–550. doi:10.4103/jnrp.jnrp_502_17
Harris OA et al. Examination of the management of traumatic brain injury in the developing and developed world: focus on resource utilization, protocols, and practices that alter outcome. J Neurosurg. 2008;109(3):433-8. doi: 10.3171/JNS/2008/109/9/0433.
Fuller A, Tran T, Muhumuza M, Haglund MM. Building neurosurgical capacity in low and middle income countries. eNeurologicalSci. 2015;3:1–6. Published 2015 Nov 9. doi:10.1016/j.ensci.2015.10.003
By Lizzy Tan