Naresh: Relearning Trauma in India

Posted 08:31 PM, August 05, 2006, by nareshr

Last night my PI showed me a picture of an MVA and asked me if it was real or staged. The victim was riding a two wheeler without a helmet and was in a head down-feet up position underneath a truck with what appeared to be open wounds and large amounts of blood on his thigh and face.

My reaction was instinctive. Having driven around quite a few similar accidents to get to school, I told him i thought that not only was the picture real, but that accidents as gory as this were commonplace. But his question made me rethink my standards. If that picture seemed unbelieveable to someone used to dealing with trauma on a day to day basis, why did it appear ordinary to me, or to my friends whom I showed it to?

I've been relearning India this summer. The first is merely recognizing that while our trauma rates and intensities are higher than back home, the care, both pre-hospital and hospital based is inadequate. Part of this I'd ascribe to an attitude that i'm complicit with when in India - what are we going to do, its too complicated, he's dead anyway.. etc.

I remember calmly following traffic filing past an accident a few years ago when a motorist (again, on a motorcycle without a helmet) lay on the tar, blood gushing onto the street from the back of his head, eyes wide open and fixed at the sky.

Second, I'm learning that the trauma that we see in India is both more numerous and more intense/varied than the varieties back home. I was always under the impression that the speeds in the West were so deadly that if you crashed, you were pretty much dead - however, in India you were more likely to crash, but the speeds were low enough to just injure, not kill.

The reverse is true. We drive in such a clean, isolated environment protected by airbags and large bodied cars and child seats etc., that the worst trauma seen in hospitals back home comes more often from gunshot wounds to the face and the like rather than road traffic accidents. The guy who drives his motorcycle here has to contend with lack of a helmet (self-imposed), direct impact with vehicles and animals of all stripes and a lack of traffic rules (more like traffic guidelines, a la Pirates).

In addition to the devastating injuries sustained, the lack of application of western standards for a trauma work up is killing more people. One part to this equation is the care received in ambulances and hospitals. The aforementioned attitude, lack of training and supplies leads to dismal attempts at support and treatment.

We saw five head injuries at the trauma center in the General Hospital this morning. Of the five, only one was in a cervical spine collar (two sizes too large for him), presumably since he complained of some neurologic symptoms. The other four were being prepped for surgery (heads shaven, disinfected) just in case. The CT scanner was 100 yards away. The trauma ICU ward was being cleaned out during the day so it was not in use. The whole setup was a receipe for disaster. Yet if the head trauma patients dont make it past the night, the blame is laid on the seriousness of the injuries.

In some cases it is frustrating to note that the prehospital care is better than that available in hospitals. Stanford Emergency Medicine International, through my PI, Dr. Mahadevan, has been running an advanced prehospital course for Apollo Hospitals, India's premier (private) healthcare center in Hyderabad and Chennai. The facilities here are comparable to those at Stanford, 64 slice Helical CT, 24 hr MRI on demand, consultant radiologists, orthopods, cardiothoracic surgeons available 24/7/365 etc.

The Apollo hospital techs whom we train are competent to manage airways and intubate patients if necessary in ambulances. However, a few of them are promptly extubated as soon as they reach a private hospital in the name of protocol since there is no one confident to manage the airway there. It is almost a shame to say that some patients would be better off going for a long ride in the ambulance than being dropped off at a small private hospital.

All said and done though, its exciting to be in India at a time when Emergency medicine has still not taken off as a specialty, but people are recognizing its importance. It is very much like what I imagine the situation must have been in the US in the 1960s, with surgeons, anesthetists and physicians passing the ball on a patient's emergent care between each other in a way that didn't always produce good results for the patient. However awareness is developing and people are on the move ... more on Indian EM in a bit ...