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Need for Trauma Center in all provinces of Nepal & Role of BPKIHS

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Pashupati Chaudhary

A trauma care system is an organized way to deal with trauma victims. This gets the right patient to the right hospital and at the right time. The nearest hospital may not be the best option for a trauma victim because he or she needs a different type of care and treatment than those given to other ill patients

According to World Health Organization (WHO), trauma is a major cause of death and disability across the world. WHO research has shown that at least 50 per cent of road crash deaths in developing countries can be prevented with effective intervention.

Trauma is Greek word meaning bodily injury. Injuries can occur from road crashes, falls, burns and interpersonal violence. But road traffic accidents or crashes are the leading cause of trauma in Nepal, making them the 5th highest cause of death and first cause of physical disability. Approximately seven persons die and several others are injured on average in road crashes everyday in Nepal

World Trauma Day is marked on October 17 every year around the world. It may sound new to Nepal, but the issue is of equal importance to this country as is elsewhere, with the ever-increasing number of accidents and injuries, resulting in deaths and disabilities, and the need to prevent them.

Being a third world developing country, Nepal has many levels of medical care. The high percentage of death rate due to road traffic accidents (RTAs) alone depicts the level of trauma care in health institutions in our country. Many areas in the country are still lacking basic health services & facilities due to poor economy, and ignorance and traditional beliefs often demand alternative approach of health care. Also in the absence of proper primary care and transportation, the patients often travel long distances, causing undue delay in obtaining proper medical treatment. Thus initial management and subsequent follow-up care becomes a prohibitive logistic problem in our country and although the infrastructure development in Nepal is gradually improving, adequate trained manpower and availability of basic facilities are inadequate or inappropriate.

As the national priority of primary health care involves mainly medical measures, the concept and practice of primary surgical care has yet to be developed. To avoid unnecessary complications, effective primary trauma care should be available at grass root level by well trained person. The lack of simple splinting at the periphery, for example, may make simple injuries more complicated by the time the patients reach the hospital. A trained general practitioner can effectively treat nearly 90% of common conditions, but until the basic requirements of facilities and equipments to treat common conditions are made available at the periphery, all attempts to depute the trained doctors( Orthopaedic surgeons)to remote and rural places will not effective. On the other hand if there were adequate facilities at the periphery it could drastically reduce the number of patients with simple ailments seeking treatment in the main referral centre’s thus sparing the consultants there for more specialized work.

In Nepal more than 80% of the people live in the rural areas while more than 80% of the qualified doctors work in the urban sectors & there is great disparity between patients & specialized manpower. Until there is improvement in the doctor patient ratio in the rural area, primary medical care & trauma care will largely depend upon the locally available, economically affordable traditional faith healers and unqualified rural practitioners.

The Orthopaedic Care in Nepal ranges from commonly available traditional healers and bone-setters in the villages to the scarcely equipped hospitals in the towns. The trained Orthopaedic persons are less than one to one million populations and these are confined to the cities & big hospitals. Moreover, the average cost of proper Orthopaedic treatment remains too high to be affordable by the average person in Nepal mainly because of little support from the existing Govt. or private health agencies. Sadly our popular rural health practitioners and bone-setters, who are mostly involved in the primary Orthopaedic care in the villages, usually do not have any formal education or training in this field.

B.P. Koirala Institute of Health Sciences, Dharan

Dharan is a lovely town situated at the foothill of Siwalik/Chure Mountains in the Eastern Region of Nepal. The summer is warm with an average temperature of 32oC and the winter is very pleasant with an average temperature of 10oC.

Dharan is connected with a domestic airport in Biratnagar about one hour drive (40km south) from Dharan. Daily national flights operate between Kathmandu and Biratnagar. Dharan is easily approachable from Bagdogra, Siliguri, and New Jalpaigurhi in West Bengal and Katihar in Bihar.

BACKGROUND

BPKIHS is a national center for providing quality health services. It is located in the eastern part of Nepal and has been taking a leading role to improve the health status of the people of Nepal by providing holistic health care through training of compassionate, caring and communicative health care workforce.

The Institute is Nepal-India cooperation. The Institute serves the health education needs of the Eastern region of Nepal at primary, secondary and tertiary levels.

Since its establishment in 1993 AD, BPKIHS has been continuously uplifting the quality of services it provides as per the needs and expectations of the people. BPKIHS has been regularly adopting the new technologies, which have proved highly effective in training the health care professionals, keeping pace with the rest of the world.

BPKIHS started its undergraduate medical education programs in 1993 presently, it is running highly successful MBBS and BDS program of the country. Post graduate medical education (MD/MS/MDS) started in 1999 and has been one of its best and most sought after programs in Southeast Asia. MS orthopaedics and traumatology started in 1999 and has produced highly competent orthopaedic surgeons, who have been leaders in their fields working in different centers, mostly across Nepal and India.

Overview of the Department

The Department of Orthopedics started from 1994 along with the MBBS course and extended its PG program since 1999. It is a high volume center treating around 1500-2000 patients/ week in outpatient department and performing 70-80 major surgeries per week. Since its establishment, department has been continuously providing the best services to the patients and education to the students. It has been upgrading its services according to the demand of time and recent advances in field of orthopedics management.

Department of Orthopaedics at BPKIHS has been active in updating to these new challenges and successful in starting quality care in fields of Spine surgery, Sports Medicine, Joint replacement surgery, Hand Surgery, Plastics and reconstructive surgery, tumor surgery and paediatric orthopaedic surgery. Being a tertiary referral health care facility of the eastern part of Nepal, BPKIHS is the largest center in terms of spine services and has a large volume of cases of the vertebral fractures and dislocations, Infections of the spine, tumors, and degenerative diseases of the spine. It also has well developed physiotherapy and rehabilitation services providing a very reliable service to these spine injury patients. BPKIHS has well functioning Laboratory facilities and most of the newer modalities of imaging required for patients with spine pathologies.

Besides its regular general orthopedics services (e.g., general out patient’s consultation, general trauma) department is providing specialized services in pelvic/acetabular surgery, foot and ankle surgery, hand and reconstruction surgery, arthroscopy and sports surgery, Complex spine surgery, Joint replacement surgery and orthopedics oncology surgery.

Department of Orthopedics has altogether 100 beds for inpatient services, 2 dedicated operation theatre running 5 days a week and emergency operation theatre running 24/7.

The Department has recently started short-term training & fellowships in spine surgery & has planned to start trainings & fellowships in trauma, Arthroscopy etc in future.

It has highly equipped and advanced Rehabilitation Center (RC) which provide best physiotherapy and orthotic/prosthesis services. It is renowned in the region for its quality artificial limbs. The department also actively participates in community oriented programs and health camps.

Need for Trauma Center in Nepal

Trauma Center’ is an advanced health institution required for the comprehensive care of the injured persons. It also offers advanced treatment to the injured persons and suitable training to the health personnel. Nepal is the one of the four countries in the world with the highest mortality rate of more than 20% due to road traffic accidents (RTA). The principal causes of RTAs remain bad road, undisciplined traffics, worst vehicles and above all improper and inadequate ‘Medical Facilities’ available at existing health institutions in Nepal.

Therefore, a growing need has been felt since last 15 years to establish “Trauma Center” on a national basis and strengthen the existing hospitals to deal with the growing demand of modern care of the injured persons mainly due to growing numbers of RTAs. The high mortality and morbidity due to RTAs has been known to cause loss of active life or limb in such poor countries where human resources are always scarce.

The prevalence of physical disability in Nepal has been estimated as 10% on an average and the principal cause being the various types of injuries affecting the locomotors system. It has also been felt that more than half of these physical disabilities could be prevented by proper primary trauma care of most common injuries.

However great the growth in RTAs, we must not forget that the vast majority of injuries, particularly those which are non-fatal, occur in the domestic setting of home, at place of work or in the street. In our country such type if injuries commonly occur due to fall from trees or hills.

Need for Trauma Center at BPKIHS

Importantly, these victims are from an economically productive age group of 20 to 40 years. This can cost Nepal great economic loss of 1-3 per cent of its GDP. Despite these facts, apart from some sporadic activities, trauma has not been addressed adequately

It is known that 20 per cent of road crash victims die on the spot from unsalvageable serious injuries like brain stem trauma. Another 20 per cent die in hospital from sepsis and multiple organ failure despite treatment. It is the remaining 60 per cent who can be saved by putting a trauma care system in place. This can be organized by putting together already available health care resources appropriate for trauma care. We must have a national trauma care system to begin with and immediately & here the role of institutional like BPKIHS come into play

Similarly, later we can have a regional trauma care system and even a local trauma care system at the regional level and local level in compliance with the present federal system of governance.

Nepal needs to develop a ‘Trauma Centre’ at different places for the specialized Orthopaedic and traumatic services, such clinical officer or trained paramedic/ practitioner seems to be the only answer to improving the treatment of the growing numbers of RTAs.

Therefore, it is essential to develop a strategy based on the available resources within the existing limitations, on improvisation, and on adaptation of modern art and science of Orthopaedic surgery to the prevailing circumstances.

* Pashupati Chaudhary: Professor, Department of Orthopaedics (Consultant Orthopaedic and Spine Surgeon) at B.P. Koirala Institute of Health Sciences,Dharan, Nepal.

** Opinions expressed in this article are the author’s own and do not necessarily reflect the editorial policy of The Asia Live.

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