The problem: An epidemic of trauma.
120 million persons are injured in low- and middle-income countries each year, the rate being 10 times higher than in high-income countries. The experience from Gaza documents that 4th Generation Warfare is an extremely brutal affair; we are facing injuries former unseen. The situation is strikingly unjust as the epidemic hits hardest in the South: Conflicts, land mines, cluster munitions, traffic accidents and natural disasters target communities that also suffer from starvation, embargo and endemic diseases.
Mass education of layperson First Helpers The scientific studies of the trauma registry in Iraq (Murad and Husum, 2010) document that early life support by trained villagers significantly reduce trauma mortality where hospitals are far away. That is why TMC trains thousands of laypersons – adults and children – in basic life support. Delegating skills and knowledge is vital in order to empower the poor and oppressed and to build resilient communities.
New strategies in trauma surgery
In most low-income countries there is a fundamental shortage of skilled health workers, and the problem increases in rural and remote areas. In a recent publication we report that a surgical training program for non-doctors at rural hospitals in the Cambodian mine fields reduced the rate of postoperative wound infection from 22% to 10%. The result is excellent. Not only does it document that that trauma surgery by non-graduates can be done with quality equivalent to that of trained surgeons. It also proves that research that makes changes can be done far away from the Academy.
Traditionally advanced life-saving surgery is conducted in larger hospitals. However, this is not an option when ambulances come under attack and war victims cannot be transferred to the central hospitals. Weapon engineers make steady progress, developing ever more sophisticated and mutilating weapons.
Care providers should therefore feel obliged to find ways of treatment that are feasible to local hospitals. Open fractures and crushed limbs are common casualties from high-energy blasts. The surgical treatment is complicated and has traditionally been centralized to specialized centers. In 2009 TMC and partners published results of a new method for limb salvage that does not require sophisticated instruments and skills. With this technique local soft tissue flaps can be mobilized for fracture healing by a handy surgeon at the local hospital.
When the land mine blasts one leg off, an open fracture is regularly inflicted at the opposite leg. Proper management of open fractures requires external fixation, but one set of instruments costs USD 6,000 which is far beyond reach for hospitals in the rural South. A local ￼rehab-workshop and research center in the Cambodian jungle is now producing surgical instruments of “export quality” based on local technology. The cost is 30% that of Western produce, and the instruments are sold together with a locally produced instruction DVD for the doctors and the rehab technicians. The workshop has capacity to serve all hospitals in Cambodia.
Warm blood needed
Blood loss is the main killer both in trauma and for poor mothers giving birth. Safe blood service at local hospitals is an urgent task. In most low-income countries the prevalence of hepatitis infections is very high. Carriers of the disease must be excluded as blood donors. With partners in Cambodia and Vietnam TMC has published reports revealing that test methods recommended by WHO are too inaccurate to be used for donor screening. Having identified the problem, work is now in progress to find feasible ways to set up “walking rural blood banks”.