|Year : 2010 | Volume
| Issue : 1 | Page : 1-4
Chain of help to patients injured in road traffic accidents: A necessity in Nigeria and other low-and middle-income countries
Editor in-Chief, Department of Surgery, A B U Teaching Hospital, Shika-Zaria 810 001, Nigeria
|Date of Web Publication||17-Dec-2010|
J G Makama
Editor in-Chief, Department of Surgery, A B U Teaching Hospital, Shika-Zaria 810 001
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Makama J G. Chain of help to patients injured in road traffic accidents: A necessity in Nigeria and other low-and middle-income countries. Ann Nigerian Med 2010;4:1-4
|How to cite this URL:|
Makama J G. Chain of help to patients injured in road traffic accidents: A necessity in Nigeria and other low-and middle-income countries. Ann Nigerian Med [serial online] 2010 [cited 2021 May 6];4:1-4. Available from: https://www.anmjournal.com/text.asp?2010/4/1/1/73858
| Introduction|| |
The type of help needed by road traffic victims varies with the severity of their injuries. In cases of minor injury, patients will often not be hospitalized but will wish to seek the help of a traditional practitioner or at most a general practitioner. Optimal medical and psychological follow-up care at this level is very important to alleviate pain and distress. In major injuries, the help provided to the victims can be viewed schematically as a chain consisting of different links as shown in [Figure 1]. Help starts with (1) action taken by the victims themselves or more often by lay witnesses or bystanders. The subsequent links in the chain are (2) access to the emergency service rescuers, (3) the help provided by emergency medical services, (4) the delivery of medical care before arrival at the hospital, (5) Specialist/ hospital trauma care and (6) rehabilitative/psychosocial care.
|Figure 1 :The chain of help to patients injured in road traffic accidents|
Click here to view
| Role of Bystanders|| |
There is no doubt that lay bystanders can play a crucial role: They can take immediate action by protecting the site of accident and thus the victim, by using a fire extinguisher if the vehicle is on fire. When the victim is in a dangerous situation, bystanders could take any necessary action to prevent further collisions or damage. Lay bystanders need to be able to recognize the most seriously injured victim that will need an urgent help, lay bystanders should be able to recognize unconsciousness and the signs of failing vital functions.  Use of protective gargets, during this process should be born in mind. The bystander should know when and where to help the patient- a safe and well-protected, well-aerated area. , He should be able to know and be very conversant on how the emergency services function and especially how to contact them and to give correct and relevant information. There is no evidence to suggest that first aid kits being made available in cars would help. Indeed, they might confuse bystanders and distract them from the essential action described above.
It is recommended that a description of the important steps to be taken by lay bystanders in the event of a road collision should be included in national Highway Codes and in car manufacturers' maintenance manuals.
| Access to Emergency Services|| |
The emergency telephone number of emergency services such as fire fighters, road safety commission and emergency medical service should be created where there is none and should be widely publicized and accessible. Travelers within Nigeria and low- and middle-income countries (LMIC) should be able to contact local emergency services timely and appropriately. The time taken to answer emergency calls should be minimized and a standard should be devised for call receipt.  Fire fighter rescuers and, in some areas, coastguards may arrive at the scene before emergency medical service personnel. It is important that fire fighters be trained in the provision of basic life support techniques and that there is training and close co-operation amongst professionals at the scene with regard to rescue from crash vehicles and safety at the scene. , Again, Nigeria and the LMICs can assist in encouraging information exchange and carrying out research in this area. Efficient and well-organized emergency medical dispatch is necessary. ,, Calls need to be transferred to a trained dispatcher able to make a layered response of the call using an appropriate dispatch system.  The Nigeria and other LMICs could assist in this process by encouraging information exchange on best practice concerning the functioning, type and operation of emergency medical dispatch systems. This is still at a very rudimentary level in Nigeria.  It is largely and sporadically done by road safety corps/marshal.
| Pre-Hospital Medical Care Requirements|| |
What treatment should be applied?
There are a range of basic life support techniques (delivered by emergency medical technicians who staff the ambulance, by paramedics, by specialist 'critical care' nurses, or physicians in mobile care units) which can be applied at the scene and during transportation to hospital. The emergency medical care system render some very important emergency medical services even at the scene of accident before victims are appropriately transported to trauma care centers. This is the world current trend. , The particular technique to be applied will depend upon the nature of the trauma. Therefore, the old method of 'scoop and run' without any treatment may be obsolete in many developed countries where emergency medical services are available and readily accessible. With this development, the 'stay and play' at scene of accident is what is being practiced commonly in developed countries. Critically ill patients are resuscitated at the scene of accident to a fairly stable enough condition to transport the patient to the nearest hospital. However, in Nigeria and most probably, other LMICs, "scoop and run" appears to be the most appropriate, so that the victim gets access to appropriate medical service early. To 'stay and play' at the scene before definitive surgical treatment can be started may be detrimental for the prognosis of the patient, particularly in a patient with major injury. Scientific knowledge about the efficacy of a range of procedures, however, is still in evolution and the optimal approach for different types of trauma patients has yet to be determined. This is an important area for Nigerian research.
| Who Should Deliver the Care?|| |
It is not economically feasible to send paramedics, a nurse or a mobile intensive care unit (MICU) to every road collision even in developed countries where emergency medical service system is well established. ,, A one tier involving emergency medical technicians or a two-tier system with, for example, emergency medical technicians as the first tier and a MICU team as the second may be set up in many developed countries.  However, the level of training and degree of professionalism varies widely from country to country. In Nigeria and other low- and middle-income countries, the victims are largely at the mercy of bystanders or passerby. In Nigeria, all too often, the job of emergency medical technician is under-valued including other LMICs where there are no well-structured, well-established emergency medical services. The Nigerian Government and other LMICs could assist in encouraging greater professionalism and encouraging better standards of training. In addition, the standards for minimum requirements for physicians staffing MICU teams could be developed at national level in Nigeria and all LMICs.
| Who Should Transport the Patients to Hospital?|| |
In most cases, the patient's mode of transportation in Nigeria is far from an ideal where airlines or very equipped land ambulances are used. In the majority of road traffic collisions in Nigeria, the patient will usually be transported with any kind of vehicle that is available, not even a land ambulance. It is recommended that standardized equipment should be used particularly in road safety commissions whose primary duty is to ensure safety measures on the roads. They are most of the time involved in transporting accident victims to the nearest hospital. They should have well-equipped land ambulances. Guidelines drawn up concerning matters such as occupant restraint, log rolling and carriage system should be included as important adjunct to the road marshals. Training standards need to be defined for ambulance drivers, road safety corps/marshals.
| By What Means Should Such a Patient be Transported?|| |
Helicopters are used widely throughout developed countries.  Although the small available literature is broadly supportive of claims for benefits such as improving response times, a review of evidence relevant task is not typically assertive. The evidence indicates that if helicopters are operated, this should be on a regional basis in a secondary responder role in response to the request of emergency personnel at the scene or at a primary receiving hospital. The ideal means of transportation still remain airline, followed by well-equipped land ambulance. In Nigeria where an ideal mode of transportation is farfetched, accident victims could be transported in ordinary ambulance, or better still, station wagon, pick up van. The bad habit of transporting accident victims in small taxi, Golf car, buses, or inside the boot of cars should be condemned and discouraged in strong terms. This is because injuries are further aggravated or made severe in such situations and many victims have got to die as result of poor handling during transportation.
| Medical Control of Pre-hospital Care|| |
Since the links in the chain of pre-hospital care are very complex, medical control and medical direction of that care may be very essential components. Input from a qualified emergency physician is necessary throughout the planning, implementation and evaluation of the emergency medical service. The audit of trauma care should be organized and supervised by all emergency physicians responsible for medical control. The Nigerian Government should encourage information exchange on best practice in this area. More so that communication networks have increased significantly in Nigeria.
| Organization of Trauma Care in Major Road Disasters|| |
The best possible way of providing adequate medical treatment is through a national or regional trauma system which may include hospital-based mobile medical teams, trained to collaborate with ambulance, police and fire services.
| Hospital Trauma Care|| |
Guidelines need to be formulated at a national level in consultation with national scientific medical societies on hospital trauma centers and their organization and co-ordination. For example, a minimum threshold of basic clinical capabilities for each trauma center needs to be established and the nature of each hospital and its resources needs to be taken into consideration. Each region should have a list of hospitals with exact details of the services that they provide and trauma care should be organized and resourced accordingly.
| Necessity of Adequate Training for Trauma Teams Managing Trauma Care|| |
The optimal standard is the ATLS course of the American College of Surgeons.  In our countries where this course is not applicable, each trauma center must still have a protocol for both the pre-hospital and hospital phase and will need to organize education and training of the personnel to use such a protocol. The trauma team leader needs to have a specific background in trauma care with certified experience. This experience should include a period sufficient to manage the treatment of at least 50 major trauma patients in emergency department level I/II level trauma centers.
| Rehabilitation|| |
Effective trauma care aims to return the injured individual to his or her place in the community and/or place of work. ,, The importance of early rehabilitation in reducing disability has been demonstrated and there is a growing acceptance that rehabilitation specialists should be available as soon as patients are medically and surgically stabilized. Patients who have sustained traumatic brain injury (TBI) will need additional specialized attention. There is increasing evidence that even relatively "mild TBI" is followed by prolonged disability in a high percentage of cases. Identification of those at special risk in this regard is not yet possible, so research is required in this area. Psychologists should be involved in the "discharge planning" of all patients with TBI and be consulted whenever there is concern about the integration of a patient back into the community. Post traumatic stress disorder is recognized as a major obstacle to full recovery after injury. It is probable that early assessment and early referral to a psychologist will improve long term outcome and speed up the recovery process. Those care givers responsible for supporting relatives of fatally injured crash victims must have special training and there must be adequate immediate help for these staff who will, in turn, often require support themselves. Best practice should be identified in treatment programs in these areas and information exchange between different Member States should be encouraged. 
| Conclusion|| |
Morbidity and mortality due to injuries from road accidents cause considerable human suffering of victims and their relatives and lead to important socio-economic costs. Many victims belong to younger age groups who are in their active years of life. This, thus, resulting in many years of life either lost or threatened by severe disability. Despite the fact that the cost in terms of years of life lost resulting from road trauma is larger than that from cancer or cardiovascular diseases, the attention and effort paid by health policy makers and by the medical community, to trauma-related care and research has not been adequately addressed. There should be deliberate efforts no matter little it may be to address these issues.
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