Dr. Stanley Aruyaru
The Village SurgeonDr. Stanley Aruyaru is a Consultant General and Laparoscopic Surgeon and a Healthcare Manager. He has solid experience in managing
By Stanley Aruyaru
The recent Horrific accident in Londiani that claimed 52 lives is a sad reminder that injury is a leading cause mortality in our country. Data available show that this year we have already lost 3000 lives to road traffic accidents. It is the moment to pause and rethink our approach to trauma care if we had to confront this challenge.
Although low- and middle-income countries (LMICs) like Kenya have fewer cars compared to western counterparts, it is sad that we have more road traffic accidents than the global north. Scholars have found this to be linked to poor transport infrastructure, weak or non-existent transport laws and poor law enforcement (few enforcement officers, corruption etc). Your guess is as good as mine on what applies in Kenya.
The transport CS has promised a raft of measures to reduce the road carnage in the wake of the weekend accident. It has struck the same chord with his pronouncements when a university bus lost control and caused an accident in Naivasha months back. Some measures like having hawkers out of the roadside may prove difficult to enforce. Though prevention is better than cure, in instances where accidents have already happened, it is important to understand how deaths are distributed and how to best reduce such deaths.
Deaths from injury occur along a temporal spread divided into 3 peaks (trimodal distribution of trauma mortality). The first peak occurs within minutes and is due to unsurvivable injuries like brain stem injury, heart rupture etc. Nearly half of deaths occur in this phase. The next peak occurs within 1 to 3 hours and constitutes up to 3 of every 10 trauma deaths. The final peak is observed days to weeks later and it arises from complications from the injuries (or intervention) leading to organ failure.
It is at the second peak where significant health intervention is needed to reduce the death rate among those injured. This is made possible by availability of surgeons, Imaging, blood transfusion and theatre services. To succeed in saving lives at this phase, we talk of the ‘GOLDEN HOUR’: the patient should be attended to within an hour of the accident. To achieve the golden hour target, well stocked hospitals with imaging (x ray, ultrasound and CT scans), theatre and blood transfusion must be set up at these accident black spots. They should then be staffed with surgeons and other healthcare staff. The Londiani sub-county hospital did not have the capacity to perform major trauma surgeries. The facility has a maternity theatre and no resident surgeon. Even getting to the county referral hospital, one finds that the emergency department, imaging department and operating theatre are not located in an optimal single section of the facility. Such hampers optimal surgical intervention within the golden hour.
Prior research has demonstrated that public hospitals along major highways handle a lot of road traffic accidents. In a similar breath, those hospitals located in communities that exhibit high interpersonal violence (domestic violence, robberies, banditry etc) see a lot of injury victims arising from interpersonal violence. This Information should guide policy on infrastructure and staffing. Both of these will call for funding.
Speaking of prevention measures, there are three levels:
✅ Primary Prevention
Ensures the problem/disease does not occur
✅ Secondary Prevention
Entails prompt adequate care after the disease has already occurred.
✅ Tertiary Prevention
This is the process of rehabilitating a patient from the complications of already suffered injury or disease.
In a recent conversation with a former Ministry of Health insider, I was impressed by the existence of a master-plan drafted during the reign of Prof Anyang Nyong’o that sought to establish regional centres of excellence. This was to consider disease burden and facility capabilities and was to capture both public, FBO and private facilities: Think of public cancer centre, private paediatrics centre, Faith based cardiac centre to name a few.
It is time to revisit such policies and implement them. Specifically, the government needs to establish trauma centres along the accident hot-spots across the country. The 2022 Kenya Demographic and Health Survey has enough details on where to start such an intervention. Perhaps this should be one of the considerations the newly inaugurated Kenya Health Human Resources Advisory Council (KHRAC) will look at. It is long overdue, for sure.
Dr Aruyaru, a consultant general surgeon, is the Chief Medical Officer at PCEA Kikuyu Hospital and the Secretary General of the Surgical Society of Kenya.
