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| HEALTH TRIBUNE | Wednesday, November 1, 2000, Chandigarh, India |
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Wanted: quality trauma care NZ surgeons’ meeting: issues Safe sex means sane society Apex court directives flouted |
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Wanted: quality trauma care
Trauma is an important health problem and injuries remain an area of very great importance. Traffic-related injuries are increasing rapidly in developing countries. Trauma accounts for more years of life lost all over the world than cancer and heart diseases. The resultant costs of long-term disability are astronomical. An analysis of the Global Burden Disease Study sponsored by the World Bank and the World Health Organisation has shown that by the year 2020, deaths from motor vehicle accidents, violence and war will increase and deaths from perinatal disorders and infections can be expected to decline. The importance of injuries might make them a primary target for national efforts to improve health. There are three principal causes of death in patients with severe injuries. (i) Immediate death resulting from respiratory impediment, leading to death within minutes, often on the scene, and probably sometimes preventable. (ii) Early death typically from uncontrolled bleeding usually within an hour or two of injuries resulting in fractures, organ injury and injury to blood vessels. (iii) Late deaths from sepsis, or multiple organ failure leading to death within days or weeks. These deaths may also be preventable by earlier treatment. These three types of death lead to a trimodal time of death distribution, with the second modal peak at 1-4 hour post injury. This observation has led to the notion of the "golden-hour". The focus is on getting patients to definitive care within this period. Half of the major trauma cases die before reaching hospitals. Hospital-based trauma services should not be the primary focus for the development of trauma services. Pre-hospital services should receive major attention. Basic life-support measures maintaining an airway, breathing, and immobilisation on a long spinal board at the pre-hospital setting need to be brought to the attention of millions and buys time for subsequent management. Because 50% of the trauma deaths occur within minutes of the injury, the prevention of events leading to the accident is the only possible remedy. Public education programmes need to be initiated though these initiatives alone are rarely successful. Enforcement (through regulation or legislation) seems to offer the most likely future benefits. The greatest benefit may be achieved when education and enforcement come together to create a cultural climate in which hazardous behaviour such as drinking and driving is prevented. Proper management in the first hour has a profound impact on events subsequent to the injury. The advanced trauma life support (ATLS) programme aims at providing a safe means to assess and resuscitate multiple-injury victims in the golden first hour. This concept of performing initial assessment and resuscitation simultaneously in order to treat the greatest threat to life has gained worldwide acceptance and has become the universal language for trauma management in the first hour. It has been shown that the ATLS programme is effective in teaching trauma management skills, increasing trauma resuscitative procedures performed in the emergency room, and improving trauma patient outcome, especially in developing countries. ATLS has changed the initial management of trauma patients. The outcome of injury can be prevented or ameliorated by good trauma care. The trauma care system should be organised to ensure that the minimum possible time to reach definitive care in a treatable condition is achieved. Only surgeons can know the despair, pain and loss during the postoperative death meeting between the exhausted surgical team and the anguished family. Trauma is a global health problem. The involvement of trauma surgeons in the prevention of injuries as well as the outcome of injury is essential to the optimal approach to reducing the burden of injury. There is an urgent need to go further from our current system in order to provide quality trauma care. The eminent psychologist, Eric Fromn, once pointed out that "the history of humanity is a graveyard of great cultures that come to catastrophic ends because of the incapacity for planned, rational, voluntary reaction to challenge". It is
time we got earnestly down to work. Dr J.D. Wig is a well-known surgeon, teacher and writer.
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NZ surgeons’ meeting: issues Lao Tzau's statement that "a journey of a thousand miles must begin with a single step" applies to caring for complicated surgical patients. Trauma is a leading cause of death and disability and it has raised the level of public concern. This problem affects both the developing and developed countries. The responsibility of managing multiple-injury patients has been placed on the shoulders of the surgeons. Are we delivering adequate care to the trauma victims? The first feature unique to trauma surgeons is the emphasis on critical care management. High-quality critical care is essential to all severely injured victims. There are many important issues that we confront everyday and everynight as we care for the injured. The timing of the trauma is unpredictable. As 50% of the deaths occur within minutes of the injury, the prevention of events leading to the accident is the only possible remedy. Advanced trauma-life-support provides a safe means to assess and resuscitate multiple injured patient in the golden first hour. This programme is effective in teaching trauma management skills. The sickest groups of patients in the hospital are in the critical care unit. Nearly 2,500 years ago Hippocrates wrote: "Life is short, the art long, timing is exact, experience treacherous, judgement difficult". An amazingly apt description of critical-care today! Critical illness goes on 24 hours a day and seven days a week. As no one can be with the patient all the time, the best critical care practitioners are those who can anticipate problems. The heart and lungs essentially function as one unit. An insult to one will tax the reserve of the other. The loss of reserve of any organ system is tolerated differently, if the insult is chronic rather than from the acute insult. Think of critical care as an infinite jigsaw puzzle. Communication with a cancer patient is extremely important to help them cope better with the disease, plan their lives, anticipate side-effects and adhere to treatment. Efforts are needed to end the conspiracy of silence affecting cancer patients and their families and friends. New models are emerging — "the informed patient", "the expert patient" and the "doctor-patient partnership". The emotional response to cancer diagnosis and surgery is highly individual. Efforts are needed to look at the challenge of providing quality care to all Indians. Many medical care-givers must modify their methods of the handling of cancer patients. Cancer development is associated with an accumulation of mutations in a number of different oncogenes and tumour suppressor genes in a multistep process which is becoming increasingly well defined. Immunotherapy, we believe, will become an integral component of a multidisciplinary approach to the treatment of cancer. As interest in long-term cancer survivership grows, breast conserving approaches offer improved cosmetic options to women undergoing treatment for breast cancer. Studies comparing the effects of different surgical options on physical symptoms and emotional health can provide a benchmark with which to measure our continued progress towards improvement not just women's survival but, importantly, their quality of life after breast cancer. These ideas will be reviewed at the forthcoming surgeons' conference being organised by the Department of Surgery at the PGI, Chandigarh, from November 10 to 12. The results of these meetings need to be consolidated into a report containing specific recommendations for policies that can facilitate access to quality care. —
J.D.W., Organising Secretary |
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Safe sex means sane society Sex is a biological need of man. Life cannot exist on the planet without sex. But God has put many checks and balances on this most important human relationship. He has tried his best to ensure that it is not taken lightly and sufficient emotional bonds develop between the two sexes before they go for an actual physical union. Surprisingly, this is not only true of human beings; even animals are quite particular in selecting their mating partners. It helps them to ensure better and healthy offspring. The Discovery Channel shows beautiful programmes about the mating behaviour of many animals and one is surprised to see that there is nothing like a casual sexual relationship among them. Incidentally, man is quite notorious for establishing non-serious physical relations. Such contacts are not made to continue the progeny but to have fun. Selective pleasure-seeking is mostly confined to human beings only. The last two decades have witnessed a sea-change in the sexual behaviour of man. Various socio-economic factors have been attributed to this change. (1) Delayed marriages: The age of marriage has gone up over the years. This trend adds to the number of people who are biologically active but have unfulfilled sexual needs. Many among them keep on looking for means to get themselves relieved of their pent-up emotions. (2) The role of the media: The media have succeeded to a great extent in giving "social sanction" to casual relations among the two sexes! I strongly feel that many popular serials on different TV channels have helped in encouraging such relationships. (3) Changing social values: Today, society shows more tolerance to relationships between the opposite sexes. In many parts of the country such relationship is considered quite normal. (4) The role of contraceptives: Since time immemorial, pregnancy was a strong deterrent to any woman going for physical relations before marriage. Thanks to various effective contraceptives and the easy availability of relatively risk-free abortions, many unmarried and married women do not think twice before crossing the line. (5) Women's "liberalisation": The woman today is no longer confined to hearth and home. She is educated, free and actively involved in all spheres of human life. Over the years, her contact with the opposite sex has increased tremendously. (6) Easy modes of travelling: Movements across the globe have increased and distances have become shorter. Frequently one comes in contact with different persons with widely different backgrounds and regions. All these factors have ensured a high frequency of male-female physical interaction. Until a few years ago, such a relationship always led to an increase in the number of sexually transmitted diseases like syphilis and gonorrhea. These diseases could be easily controlled with antibiotics and one could easily get treatment after getting exposed to the infections. But now there is one infection for which there is no cure. It has 100% mortality rate. You can't get it cured but you can always prevent it. I hope that you would have guessed. It is the HIV infection (AIDS). HIV-infection in India: There may be some controversy regarding the figures about the prevalence and incidence of the HIV infection in the Indian population, but there is a general agreement about the following observations:— (i) The number of the HIV positive cases is on the rise and this rise is very steep. No segment of Indian society is free from HIV. (ii) All our efforts have failed to slow down this rise. (iii) India has the largest pool of HIV-positive cases. (iv) Promiscuity is increasing in our populace. (v) The HIV infection is widely prevalent among the sex workers. (vi) The majority of the young people who visit sex workers do not use protective measures. (vii) Our facilities to handle such a large number of HIV positive cases, which have all the potential to turn into AIDS cases, are grossly insufficient. (viii) Since there is no specific treatment for AIDS, the only successful way is to prevent it. (ix) In many African countries, which are badly under the grip of HIV, this infection has become a nightmare for the administrators and the people, and has destroyed their economy and socio-cultural fabric. (x) Countries like the USA have succeeded in controlling the rising tide of the HIV infection through intensive health education and public awareness. I have been regularly dealing with cases coming with various psycho-sexual problems and one thing which has often occurred to me is that a vast majority of young boys visiting sex workers or having casual sex with their girl friends or other females do not use condoms. They are aware of the fact that they are putting themselves at a great risk of the HIV infection and other sexually transmitted diseases. But, they are not prepared or motivated to avoid such relations or to use protective methods. Considering the vast pool of HIV positive cases in our country, such behaviour is full of fatal hazards. It is important to remember that this message has to be hammered in the minds of our people — not once but a hundred times. Dr Gupta is a practising psychiatrist, medical editor and public educator of eminence based at Ludhiana. |
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Apex court directives flouted It would not be an exaggeration to state that the current status of the blood programme in the country is precarious. It is on this account that the Supreme Court, after examining the deplorable state of this programme, directed the health authorities to take immediate remedial measure for revamping the blood transfusion services. The rapidly increasing demand of blood for therapeutic purposes concurrently brings forth the problem of the increased risk to the patients. The safety of the recipient needs be ensured. As a result of the intervention of the apex court, an expert committee was asked to study the problems which were hampering the development of this programme and to suggest positive measure. It may sound strange but the fact of the matter is that the conditions observed by the expert committee were found to be much worse than those contained in the original petition. Keeping in view the existing set-up and the working pattern of the blood transfusion services, it is imperative to evolve a national plan for the eradication of commercialisation and professionalism in blood banking. Besides technical standardisation, a lot needs to be done to attend to various social, ethical and legal aspects of the problem. This will help achieve the ultimate goal of technological development and eliminate the hardship of blood procurement. For revamping the existing set-up the Expert Committee on Blood Transfusion Services made the following observations: (a) The overall situation in the country being highly unsatisfactory, it calls for immediate effective measures to revamp and develop the services in this field. (b) The quantity of blood available falls short of the amount required, leading to prevailing malpractices. In spite of all the claims from various quarters, a considerable proportion of the supplies still continues to be obtained from high-risk donors. The quality of blood and the standard of services are extremely poor, thereby exposing the recipients to the danger of serious transmissible diseases. (c) There is hardly any manpower worth the name which can handle the present situation in introducing good manufacturing practice or quality control and meet the requirement of services or undertake their improvement. Regular postgraduate training courses for medical and paramedical workers are hardly available anywhere in the country. (d) There are too many bodies engaged in this work, making it impossible to have a uniform standard, proper monitoring and coordination. Any effort towards developing the programme will necessitate a central monitoring agency which can coordinate and exercise an effective control over all the agencies engaged in different aspects of the programme. (e) Whereas the governmental agencies claim to have modernised a large number of blood banks managed by the central and state governments, an in-depth study does not provide any evidence of modernisation anywhere in the country. Whatever may be the existing standards, we cannot afford to let the situation remain in such a deplorable condition. (f) The ever-increasing number of medical centres in the private sector and nursing homes depend primarily on professional blood-sellers. Even the hospitals attached to medical colleges and other government institutions mainly depend on professional blood-sellers either directly or through commercial centres. (g)
Even in medical colleges, the standard of blood transfusion is almost primitive. They use glass bottles for the collection of blood instead of plastic bags and primarily depend upon whole blood rather than making efforts at developing components. The standardised procedures for the processing and screening of blood are hardly being practised. (h) All talk of voluntary blood donation all over the country appear hypothetical. This is obvious from the fact that, even today, out of the total collection in the country, more than 50% blood is being obtained from professional blood-sellers. It is not infrequent that professional donors invariably appear in the garb of relative donors and many states continue the nefarious practice of depending on high-risk prisoners and captive groups for blood collection. In view of the above, we cannot afford to delay the launching of a powerful drive for revamping. Serious thought needs to be given to the Supreme Court directives to ensure their implementation all over the country. Let us hope that something concrete will be done by the custodians of health to ensure the availability of safe blood. (Concluded) Dr J.G.Jolly is Professor Emeritus in the Department of Haematology and Blood Transfusion at the PGI, Chandigarh. |
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