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Rapid Responses: Rapid Responses published:
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Road Mortality in Developing Countries and Aid
- Gregory Rose (13 April 2004)
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DANGEROUS MOVES
- Anil K Chawla (14 April 2004)
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Death on the roads: the chance of life for some?
- Alastair D Smith (11 May 2004)
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Moving trauma care on from the Prima Donna mentality.
- Rowland L Cottingham (28 May 2005)
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Gregory Rose, Public Health Specialist formerly Consultant WHO Phnom Penh
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Editor -- Roberts and Abbassi (1) are right to highlight disproportionately low spending on preventing road injuries compared to more popular investment areas. Perel et al.(2) address the gaps in road safety in developing countries. The risks in developing countries are high since protective clothing, road rules, driver training and speed limits are often absent. It may come as a surprise to some that the annual rate of injuries and mortality from road traffic accidents overtook those related to UXOs (unexploded objects - bombs) and landmines in Cambodia in 1998. Traffic accidents have continued to rise in number and severity since. Keep in mind that Cambodia, with Angola, has been at the top of the list of landmines per capita. One aid donor, Japan, contributes a good deal to bridges/roads. Many Cambodian bridges were destroyed by fighting or else by torrential rain and lack of maintenance with the collapse of public infrastructure. In recent years Cambodian roads have become more efficient and faster while public transport systems (trains) have decayed. Roads, rather than becoming safer with the removal of potholes, have become more efficient at killing. Highways carry plaques announcing donor country assistance in the building of bridges and roads while the tell-tale chalk marks made by police show the outlines on roads of bicycles and bodies in Agatha Christie style. Japan holds a virtual monopoly in automobile sales in Cambodia, so the integration of aid and investment is convenient. Many of these sales are of powerful 4-wheel drive vehicles which are never intended to go off road but instead are status symbols for the rich. Socio -economic inequality in road deaths does not require research. Some non-governmental organisations leading on disability issues, along with the Red Cross, have worked towards increasing safety for the most vulnerably (motorcycle taxi riders) – employing fluorescent jackets, defensive driving training courses and helmets. This is valuable work which should be built upon and expanded to include government agencies. However, donor countries which inadvertently contribute to deaths on such a massive scale should, one could argue, take a more direct approach to protecting those they purport to help. Development, including enforced road rules, the finance for safety equipment and training, and designs to protect slower road users (child and elderly pedestrians, bicycle and motorcycle riders) should be a condition of investment for donor countries. This would involve a tiny fraction of their profits. UXOs and landmines and infectious diseases are a more attractive option to donors especially when the cost of their investments is so seldom understood. 1. Roberts I, Abbassi K. War on the roads: two years on. BMJ 2004; 328: 845 (10 April) 2. Perel P, McGuire M, Eapen K, Ferraro A. Research on preventing road traffic injuries in developing countries is needed. BMJ 2004; 328: 895 (10 April) Competing interests: None declared |
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Anil K Chawla, Senior Specialist in Medicine Royal Hospital, P.O.Box 1331, P.C. 111, Muscat, Oman
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If you enter somehow a ‘No entry’ zone,
You’re a great man; you’ve a love of the thrill,
You’re a funny guy, love to chat on the wheel,
You great guy, you think yours is the road,
‘Drinking and driving don’t mix’ they say;
“I wear no helmet; I love no seat belt,
Didn’t sleep well or took drugs to fall asleep?
AND THANK YOU EVERYONE FOR LISTENING TO GOOD SENSE. Competing interests: None declared |
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Alastair D Smith, Assistant Professor of Medicine, Division of Gastroenterology and Hepatology Rm 105, Bell Research Building, Trent Drive, Duke University Medical Center, Durham. NC. 27710. USA.
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Tragic and wasteful though death as the result of road traffic accident (RTA) is, the opportunity for solid organ donation and procurement arises (liver, kidneys, heart, and lungs). 1 Whilst it is incumbent upon governments and institutions such as the Medical Research Council to demand and develop strategies for reduction of deaths from RTA, it is not unreasonable to believe that the same groups should promote every effort to support and sustain organ donation from deceased persons in such circumstances. Thus, some good might arise from an otherwise hopeless and seemingly futile situation. It is not stated among data on the European Liver Transplant Registry website, 2 nor in the recent paper on behalf of the same group what proportion of patients undergoing orthotopic liver transplantation (OLT) did so with an allograft from a deceased donor (DD) who died as the result of a RTA. 3 Of 5183 patients undergoing OLT from a DD in the USA between 1st July 2002 and 30th June 2003, 22.9% of recipients gained their allograft as the consequence of motor vehicle accident. 4 However, these figures give no indication as to the numbers of patients whose death as the result of RTA led to successful organ procurement for transplantation. Furthermore, so long as disparity in the laws regarding the status of deceased persons with respect to consent for organ donation exists between countries, e.g. Spain and the UK, then the opportunity for organ procurement and the gift of life for otherwise dying people will remain unfulfilled. References: 1. Roberts I, Abbasi K. War on the roads: two years on. BMJ 2004;328:845. 2. European Liver Transplant Registry. Available at: http:// www.eltr.org. (accessed 8th May 2004). 3. Adam R, McMaster P, O’Grady JG, Castaing D, Klempnauer JL, Jamieson N et al. Evolution of liver transplantation in Europe: report of the European liver transplant registry. Liver Transpl 2003; 9: 1231-43. 4. Scientific Registry of Transplant Recipients. Transplant statistics: national reports. Available at: http:// www.ustransplant.org (accessed 7th May 2004). Competing interests: None declared |
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Rowland L Cottingham, Consultant in Emergency Medicine, Vice Chairman, Sussex and Surrey Immediate Care Scheme Brighton and Sussex University NHS Trust BN2 5BE
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Almost 20 years ago, Spencer asked why we did not make use of the concept of trauma teams (1). Many hospitals in the UK followed this advice, and now deploy such teams. Are they actually functioning as teams, though? I sometimes have the opportunity to escort seriously traumatised patients into other units, and did so again recently. Not for the first time, I found it profoundly depressing to watch. No trauma team had been assembled to meet us, but a pleasant young SHO did arrive. I gave him the story. He listened attentively, and appropriately started to examine the area of my major concern. A passing Resuscitation Officer ably assisted. A nurse then arrived and asked if he wanted a trauma team. He paused and said yes, he‘d better have one. From that promising start, it all went downhill. Five doctors of varying ages and seniorities arrived, and in sequence went up to the patient, barked the same questions at him and then started giving each other, the nurse and the poor SHO orders. The paramedics and I were ignored, and a power struggle ensued over the subsequent 23 minutes while one drip was put up on the patient. Voices gradually rose as each doctor attempted to assert team leadership. The oxygen mask he was wearing on arrival disappeared. His physical handling was rough and empathy nonexistent. The SHO timidly mentioned my clinical concern, which was dismissed after a desultory examination. I left at this stage, just as the patient radiographer was finally taking the first Xray. I am an ATLS instructor, and ATLS courses still start with the little fairy tale about the surgeon crashing his plane near a hospital with one seemingly clueless doctor. The plane-crasher then saves the day by treating his own family. Arguably, ATLS has done more to improve trauma care world wide than any other intervention, but the command and control system of ATLS is very different from other treatment in the UK, based on collaborative decision making. We need to accept that trauma care 20 years on is no longer given in the developed world by a single doctor but a team. We may have reached the stage where ATLS produces prima donnas intent on claiming their 15 minutes of fame as team leader, and is not turning out team members looking to give best care to the patient collectively. We need to change the focus of the ATLS philosophy (now that we have most of the medicine right) and look to produce team members who do not spend their time telling each other what to do. A separate course should be created to teach team leadership. 1. Spencer JD. Why do our hospitals not make more use of the concept of a trauma team? BMJ 1985;290:136-8. Competing interests: None declared |
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