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REVIEWS: Ian Roberts Trauma Africa BMJ 2005; 331: 114 [Full text]

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Trauma in Africa.

Douglas M Bowley, Euan J. Dickson, Nigel Tai, Jacques Goosen, Kenneth D. Boffard.   (25 July 2005)

Trauma in Africa. 25 July 2005
Douglas M Bowley, Honorary lecturer, Department of Surgery University of the Witwatersrand, Johannesburg, Euan J. Dickson, Nigel Tai, Jacques Goosen, Kenneth D. Boffard. Send response to journal: Re: Trauma in Africa.	Injury is a major cause of morbidity and mortality around the world and the burden falls disproportionately on the developing world. Our Trauma Unit, the focus of a BBC documentary earlier this year, encapsulates many of the problems experienced across the continent. Despite an increase in population size across South Africa, deaths from non-natural causes have shown an absolute fall in numbers.(1) Although numbers may be decreasing nationally, our hospital (close to the urban slum-areas of central Johannesburg) has seen an increase in trauma volumes. Between 1997 and 2004, the total number of patients requiring resuscitation for life-threatening trauma at our unit increased by 56%, six percent were children below the age of 16 years. In 2004, approximately fifteen patients with gunshot wounds required resuscitation every week (an increase of over 60% compared to 1997), while the number of priority one stab-wounded patients more than doubled. The other major injury mechanism to show a dramatic increase is pedestrian vehicle accidents (PVA); in 2004, approximately six patients required resuscitation for PVA every week, an increase of 58% compared to 1997. Penetrating injury accounted for 51% of the resuscitation workload in 1997, whereas in 2004 this proportion had increased to 59%. Most of the deaths from injuries in South Africa occur among non- white males in the economically active age range of 15 to 44 years.(2) The leading cause of these deaths for males is homicide. Among females, accidents are the leading cause of unnatural death; children suffer predominantly from burns and PVA.(2) Urbanisation and growth of major metropolitan cities is a key characteristic of the developing world. In May 2002, the Executive Director of the United Nations Human Settlements Programme (UN-HABITAT) described the global trend in urbanisation as “simply too fast to provide and manage basic services for all”.(3) Worldwide, the number of urban dwellers living without adequate shelter and basic services is expected to reach two billion by 2025. Urbanisation leads to household-crowding and poverty, recognised risk factors for pedestrian accidents. School age child are at particular risk as they often live in areas with high traffic volumes and density, with few alternatives but the street for play and inadequate parental supervision. The increase in pedestrian accidents seen at our unit is in direct contrast to the situation in more affluent nations; a 49% reduction in the number of deaths of child pedestrians has been documented in the US between 1978 and 1992.(4) Urbanisation worsens unemployment, overwhelms provisions for shelter and basic infrastructure and when combined with poor social services and disparities between the ‘haves’ and ‘have-nots’ results in a high degree of social exclusion leading to social dysfunction, crime and violence. Substance abuse is common and in South Africa, 76% of all deaths after interpersonal violence have been shown to be alcohol related.5 Seven percent of drivers with illegal blood alcohol levels have been shown to account for 47% of driver deaths. Pedestrian accidents account for over 70% of adult traffic deaths and alcohol is often a factor.(5) In a recent study of major trauma patients from our institution, 59% were positive for blood alcohol. The average blood alcohol concentration in our patients was more than three times the legal limit for driving and more than 40% of the patients were positive for urinary cannabis.(6) Over 90% of our trauma unit nursing and medical staff have experienced verbal abuse, three quarters have been threatened with violence and 42% have experienced violence from patients within the previous two years.(7) Nurses are more likely to have experienced violence than doctors. The most ‘emotionally disturbing’ incidents for staff were those involving injured children or sexual assault, incidents which, in South Africa are unfortunately all too common. Female members of staff and nurses have the worst symptoms of post traumatic stress and the proportion of trauma unit staff reporting high degrees of burnout was about 1.5-fold greater, in terms of emotional exhaustion and depersonalisation than occupational groups found to have the highest risk of burnout in other published studies.(7) Serial exposure to critical incidents increases the risk of burnout. This results in a progressive loss of the ability to feel emotionally involved in one’s work, which leads to a cynical attitude towards patients, compromised care, dissatisfaction and high staff turnover. Our trauma centre attracts foreign health-care practitioners who work in the unit for relatively short periods of time. This is a mutually beneficial arrangement, but local staff are our backbone and we can ill afford them to leave to work in other, less stressful environments locally or go overseas. Although the numbers of non-natural deaths in South Africa appear to be reducing, the proportion of firearm-related and pedestrian deaths appears to be increasing and the burden of hospital care due to trauma has fallen increasingly on certain institutions. The impact of abuse of alcohol and illicit drugs is a major contributor to trauma in our society. Further interventions aimed at lessening this impact are urgently required. The burden of caring for victims of trauma weighs heavily on our staff, particularly nurses, who have to deal with distressing events, violent patients, and work in an environment of high HIV seroprevalence (in 2002, seroprevalence for HIV was 37% in a series of our major trauma patients).(8) Africa is blighted by trauma and urbanisation is making matters worse. Efforts are required at all levels to ensure development proceeds with injury reduction strategies to the fore. While this process occurs, recognition of the high levels of stress on health workers stresses by hospital authorities should lead to enhanced provision of care towards our own workers. Reference List 1. Mortality and causes of death in South Africa, 1997 - 2003: [online]. Available: http://www.statssa.gov.za/publications/P03093/P03093.pdf. 2005. 2. Medical Research Council of South Africa: [online]. Available: http://www.mrc.ac.za/pressreleases/2001/18press2001.htm. 2001. 3. United Nations Human Settlements Programme. UN-HABITAT: [online]. Available: http://hq.unhabitat.org/programmes/agenda21/documents/urban_trialogues/forewords.pdf. 2002. 4. Rivara FP, Grossman DC, Cummings P. Injury prevention. First of two parts. N.Engl J Med 1997;337:543-8. 5. van der Spuy JW. Trauma, alcohol and other substances. S.Afr.Med J 2000;90:244-6. 6. Bowley DM, Rein P, Cherry R, Vellema J, Snyman T, Boffard KD. Substance abuse and major trauma in Johannesburg. S.Afr.J Surg 2004;42:7- 10. 7. Crabbe JM, Bowley DM, Boffard KD, Alexander DA, Klein S. Are health professionals getting caught in the crossfire? The personal implications of caring for trauma victims. Emerg.Med J 2004;21:568-72. 8. Bowley DM, Cherry R, Snyman T, Vellema J, Rein P, Moeng S et al. Seroprevalence of the human immunodeficiency virus in major trauma patients in Johannesburg. S.Afr.Med J 2002;92:792-3. Competing interests: We all work, or have worked, in the Johannsburg Trauma Unit and are committed to improving trauma care.