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 Table of Contents  
REVIEW ARTICLE
Year : 2019  |  Volume : 5  |  Issue : 1  |  Page : 12-18

Road traffic-related injuries need to develop capacity building to provide comprehensive care


1 Department of Biochemistry, Calcutta Medical College, MGM Medical College and LSK Hospital, Kishanganj, Bihar, India
2 Department of Community Medicine, MGM Medical College and LSK Hospital, Kishanganj, Bihar, India
3 Department of Emergency Medicine, University of Florida Jacksonville, Jacksonville, USA
4 Ex-Director of Health Services, A&N Islands, Port Blair, Colombia
5 Advocate, The Supreme Court of India, New Delhi, India
6 Department of Dermatology, Venereology and Leprosy, MGM Medical College and LSK Hospital, Kishanganj, Bihar, India
7 Department of Forensic Medicine and Toxicology, All India Institute of Medical Sciences, New Delhi, India
8 Department of Neurosurgery, Red Latino Organización Latinoamericana De Trauma Y Cuidado, Neurointensivo, Bogota, Colombia
9 Department of Neurosurgery, Narayana Medical College and Hospital, Nellore, Andhra Pradesh, India

Date of Submission11-Apr-2018
Date of Acceptance10-May-2018
Date of Web Publication23-Apr-2019

Correspondence Address:
Dr. Amrita Ghosh
Department of Biochemistry, Calcutta Medical College, Kolkata, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJAM.IJAM_13_18

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  Abstract 


Every year around the world, millions die on road generally from preventable causes and are major public health threat in current times with soaring figures of unnecessary and unacceptable burden of morbidity and disability. We attempted an extensive collection of published literature with specific inclusion criteria in PubMed, Cochrane, Web of Science, and WHO Global Health Library including additional search in indexed literature and website-based population survey reports. Ten percent of road accident fatalities worldwide occur in India, and in addition, more than a million are grievously injured every year. Moreover, victims with nonfatal injuries are forced to live with a range of physical and emotional disabilities with a colossal social and economic impact. In addition, the health-care costs allied with these injuries also create an immense threat to the already stretched out curative health-care load particularly in resource-poor settings of the developing third world countries. Notwithstanding such sobering data, road traffic injuries received less than optimal interest from national health planners to provide comprehensive care from primary health-care levels where maximum injuries come as first contact intervention. Injuries are not accidents and they do not occur by chance alone; like morbidity, they follow a classical model of epidemiological triad of agent-host-environment. Hence, by classifying the risk factors for injury as modifiable and nonmodifiable, it is most likely to forecast and prevent by models. There is a great need to validate brain injury biofluid biomarkers in the acute care setting such as in the emergency departments.
The following core competencies are addressed in this article: Medical knowledge, Patient care and procedural skills, and Systems-based practice.

Keywords: Capacity building, comprehensive care, road traffic-related injuries


How to cite this article:
Ghosh A, Pal R, Galwankar S, Paul SK, Sinha D, Pal S, Jaiswal A K, Moscote-Salazar LR, Agrawal A. Road traffic-related injuries need to develop capacity building to provide comprehensive care. Int J Acad Med 2019;5:12-8

How to cite this URL:
Ghosh A, Pal R, Galwankar S, Paul SK, Sinha D, Pal S, Jaiswal A K, Moscote-Salazar LR, Agrawal A. Road traffic-related injuries need to develop capacity building to provide comprehensive care. Int J Acad Med [serial online] 2019 [cited 2019 Aug 21];5:12-8. Available from: http://www.ijam-web.org/text.asp?2019/5/1/12/256792




  Introduction Top


Medical science has gifted us with the knowledge and competency to save lives even with near-fatal injuries, for which the victim needs to be transported to the definitive care center to receive the benefits. In the road crash situations, we lose valuable lives of millions of our citizens in the absence of emergency medical services; the concept is quite new to citizens of India even in the metros. These figures are more on the higher side for countries like India, where both the roads and vehicles lack the basic safety norms. By and large, the role of law enforcers for responsible monitoring of safety norms on Indian roads could not reach our expectations. Global status report on road safety 2015 advocated “Safe Systems” in changing of road user behavior on key risk factors mentioned above.[1] Further, Bloomberg Philanthropies Initiative for Global Road Safety 2015–2019 targeted to trim down mortalities and injuries from road traffic crashes in low- and middle-income countries by strengthening road safety legislation with proven road safety interventions.[2],[3] Recent WHO data showed that worldwide each year four lakhs under 25 years people die on roads, i.e., more than 1000 a day for which various urgent measures have to be taken to reduce road traffic crashes, through intersectoral participatory contributions in line with sustainable development goals (SDGs).[4],[5]


  Methods Top


We attempted a wide-ranging collection of study reports by exploring various resources viz; published surveys, and field studies, meeting presentations, and personal communications about recent works not included in previous analyses in which road traffic injuries were reported. Through an extensive search in indexed literature and website-based population survey reports, we identified 45 research publications from 300 potentially relevant articles. All published articles in indexed journals available from various institutional libraries of India and websites on epidemiologic and analytical studies on road traffic injuries were also searched. The search terms included combinations of MeSH terms and empirical taxonomies such as investigation, management, follow-up, guidelines, prediction model, randomized controlled trial (RCT), and outcomes including deaths in PubMed-entrez: (January 1, 2000–December 31, 2017), Cochrane Library (January 1, 2000–December 31, 2017), Web of Science (January 1, 2000–December 31, 2017), and the WHO Global Health Library (January 1, 2000–December 31, 2017) including searching of abstracts from scientific meetings (2000–2017) and abstracts from scientific meetings (2000–2017). Review of citations and reference lists was performed to identify additional studies. Wherever possible, sources were contacted for further information on survey data not readily available in the public domain. Manual searches were conducted from review articles, previous meta-analyses, and also from hard copy publications not sourced in repeated internet searches. Whenever possible, we tried to contact authors for additional information or for translations from languages other than English regarding road traffic injuries.

Few criteria were developed to select studies from among peer-reviewed articles. First, a broad criterion of road traffic injuries was developed on information provided in the WHO publication by the global experts before the study for ensuring feasibility, acceptability, and reliability. Second, road traffic injuries with body regions involved and patterns of injuries, clinical presentation, demographic distribution, investigation, management, follow-up, guidelines, prediction model, RCT, and outcomes including deaths were sought to be included; studies that did not meet these criteria were excluded from the study. Finally, in the absence of nationally representative database on road traffic injuries and nonconcurrence of the researchers regarding the common pattern of reporting in literature in India, all the reports on road traffic injuries were considered in this review irrespective of criteria of diagnosis.

Main outcome variables

The main outcome variables of this study were to capacity building on injury and comprehensive injury care.

Citizen's charter

To curtail the susceptibility to injury of citizens in the community, systematic interventions should be started by the first responders, namely, police, firemen, ambulance staff, driver, and bystander with ABCDE care and hemodynamic stability as the initial resuscitation measures.[6],[7] The reality of the situation is that people tend to be apathetic or practice scoop and run to reach the nearest health facility which may also worsen the extent of injuries primarily sustained by the victim.[8] Factually, the latter approach is one of the common actions in the absence of dedicated training to citizen at large and first responders in particular. Further, protocol-based training and provision of specific equipment (spinal boards and cervical collars) as part of ambulance logistics amplify the effect of prehospital care. The prehospital care training needs to be sincerely implemented widely for the first responders across the lengths and breadths country for the earliest interventions with minimum investigations for optimum outcome predictions in all road crash incidences to transcript the updated knowledge of the injury science to the last man on the road.[9]

Prehospital trauma care

The prehospital care increases the survival as described by tri-modal distribution of outcomes viz. first at the spot, second within minutes and then to a few hours post-injury are the active focus of prehospital and hospital care. These victims of Road traffic Injuries (RTIs) have better salvageability in the “Golden hour” or “Platinum 10 min.” One-third of fatalities could have been avoided by implementation of a comprehensive trauma care focusing on life-threatening injuries.[10],[11],[12],[13] Prehospital trauma care fundamentally relies on standardized time-sensitive algorithms. Injury mechanism associated with vehicle as well as property damage, scene safety, and extrication are crucial determinants of the outcome of a traumatic event. Proper immobilization of the injury site of critically injured before transfer to hospital is key to prehospital trauma care.[14]

Poor infrastructure for managing RTI at primary health-care level

Road traffic injuries lead to a range of injuries ranging from abrasions to maxillofacial injuries and even to polytrauma. The Government of India envisages improving trauma care by establishing extensive network of trauma care centers and hospitals with the facility of trauma care along major highways. Enforcing of traffic rules is necessary for the emergency traffic flow to improve trauma care in the Indian scenario. Formation of road safety database and strengthening of driving license system with road safety enforcement are imperative measures required to be strictly initiated and implemented. Representation from the Ministry of Road Transport and Highways needs to be supplemented with the Ministry of Health and Family Welfare, State Public Works Departments, public sector, and private sector including non-governmental organizations to take necessary measures in this direction.[15],[16]

Injury-related disability and rehabilitation

Globally, more than a billion persons live with disabilities and majority of them are from low-income and middle-income countries of which a significant proportion are result of road traffic crashes. Injuries and violence affect across all ages, races, and socioeconomic status we know that the majority of injuries affect mainly young people mostly from low- and middle-income countries; many are left with incapacitating sequelae and permanent disabilities.[17],[18],[19],[20] Temporary and permanent disabilities are sequel of the road crashes with socioeconomic and psychological effects. The after results are quite intriguing and lead to many compromises.[21] Global, regional, and national level estimates of the injury-specific causes of disability are generally lacking. However, estimates from some countries suggested that one-fourths of disabilities may result from injuries. Injury-related impairments resulting in disabilities include physical as well as cognitive limitations due to neurotrauma, paralysis, amputation of limbs, limb deformation resulting in impairments, psychological trauma, blindness, and deafness. Lack of access to health and rehabilitation services, education and employment, and expensive medical care limit the disables to full social participation with the improvement of the activities of daily living. WHO Helmet initiative and other activities reduce consequences from road crashes by improved emergency care and rehabilitation.[22]

Traumatic brain injury as a major cause of concern

India has shortcomings in the present trauma management system embracing all disciplines amid growing load. In our infrastructure poor health-care delivery system, we need to work out for optimum outcomes in injury care for which methodical approaches with insight on prevailing reality is the call of the day.[14],[23],[24] Globally, professionals in this field of research have estimated traumatic brain injury (TBI) to be the third most common cause of mortality and disability by 2020 and likely to outshine other noncommunicable diseases by next decade. Among injury spectrum, TBI is a most important risk correlate of morbidity, mortality, and disability which demands unfailing protocols for outcome prediction on admission and specialized neurosurgical care. Long back Hippocrates predicted “No head injury is too severe to despair of, nor too trivial to ignore.” In this parlance, the Glasgow Coma Scale and the Glasgow Outcome Scale provide convincing predictions after 24 h.[25],[26],[27],[28] Each country needs dedicated researchers to forecast projectile load and sociodemographic uniqueness of TBI for a holistic approach for effective, comprehensive prevention activities, policy improvement, and planning to pledge acceptable standard health care for our citizens at the dire needs. These challenging painful soul-searching efforts will be able to detail out potential predictors of outcomes of victims of TBI.[29],[30],[31],[32]

Researches on biomarkers of traumatic brain injury

Literature reports many studies exploring promising injury biomarkers during the last few decades measured through a simple blood, or other body fluids can provide invaluable information about the management of acute brain injury to facilitate diagnosis. Researches on the risk stratification by variety of prognostic biomarkers are promising; yet opinions are divided regarding their sensitivity and specificity. These are S100 β, the biomarkers of astroglial injury for mild TBI; and glial fibrillary acidic protein for severe TBI; neuron-specific enolase increases in serum following central and peripheral neuronal cell body injury; ubiquitin C-terminal hydrolase-L1 biomarker for TBI; alpha-II-spectrin breakdown products reported in CSF from adults with severe TBI have shown a significant relationship with severity of TBI and clinical outcome; tau intracellular, microtubule-associated protein shows early elevated cerebrospinal fluid levels in severe TBI patients to predict elevations in intracranial pressure and to be associated with poor clinical outcome; neurofilaments are heteropolymeric components of the neuron cytoskeleton.[33],[34],[35],[36],[37],[38]


  Key Recommendations Top


Road safety intervention can be implemented at the following multiple stakeholder's levels

Roads

All roads should compulsorily be constructed based on scientific background on town and country planning as per long-term sustainable development perspectives of the country in general and areas of the countries in particular. All roads to have futuristic provisions of widening to accommodate enough spaces to reach expectations of needs, vehicle density and provided with adequate road safety prerequisites viz. lighting, signals, and pedestrian movements. There should be special attention to safety needs of children, senior citizens, and persons with special needs.

Man and animal

We need separate walkways for cyclists and pedestrians that should be strictly adhered to with heavy penalty levied to all defaulters. As per the local needs, all the roads have to be widened from 2 lanes to more lanes. All two wheelers and four wheelers drivers must be directed to adhere to lane driving strictly. No cattle or other domesticated animals be allowed to roam in the roads for which all animal owners must be sensitized that they will be pounded for with provision of heavy fine in cases of trapping of their animal by legal authorities.

Role of governments

Government should form a central body on road safety and standards, headed by the Ministry of Road Transport with state branches responsible for formation and implementation of road safety regulations and legislations across the country. The following steps to be taken strictly:

  • Improve quality of national statistical database related to road safety
  • Introduce Road Safety Surveillance and Trauma Registries at Union Level with state and district level registries
  • Update transport policies and traffic rules in line with upgrading of automobile industry and enforced for safety of all strata of population based on sound data
  • Enforce the driving license system and standards for vehicle condition
  • Speed limits to reduce the mortality and morbidity
  • Strictly law on drunk driving with clear legal definitions and blood alcohol concentration (BAC) limits set at or below 0.05 g/dl. Additional BAC limits, below 0.02 g/dl, may be considered for the young or novice drivers
  • The use of front and rear seat belts should be mandatory for three wheelers (auto-rickshaw) along with four wheelers and above vehicles
  • Introduce helmet wearing policy concurring UN Regulation No. 22. Motorcycle helmets should comply with the national standards and increase awareness at the political level to encourage use of appropriate helmets. Children should be allowed on two-wheelers only when they are older and tall enough to be transported. Make helmets more affordable in low-income countries
  • Road safety education should be included from kindergarten to postdoctoral levels with level-specific programs.


The Union Ministry of Road Transport and Highways released “Road Accidents in India 2015” compiled by the Transport Research Wing. The report recognized that road accidents are a major public health problem in India; the total number of road accidents raised by 2.5% from 489,400 in 2014–501,423 in 2015 and the number of persons killed in road accidents increased by 4.6% from 139,671 in 2014–146,133 in 2015; 1374 accidents and 400 deaths take place daily, translating into 57 accidents and loss of 17 lives every hour. According to the report, Mumbai had the highest number of road accidents, while Delhi had the highest number of deaths on road.

This document has proposed ten golden rules for road safety.[39],[40]

  1. “Stop or slow down: Allow pedestrians to cross first at uncontrolled zebra crossings
  2. Buckle up: So that your family and you are safe in the car. Seat belts reduce the chances of death of a car occupant in accidents
  3. Obey traffic rules and signs: To prevent road accidents
  4. Obey speed limits: For your own safety and that of others, ideal speed should be 20 and maximum speed limit 30 kmph near places of residences
  5. Keep vehicle fit: To prevent breakdown and accidents on the road
  6. Never use mobile while driving: To avoid distractions that lead to accidents
  7. Wear helmet: To protect your head while riding a two-wheeler. A good quality helmet reduces the chances of severe head injury
  8. Never drive dangerously: To ensure your own safety and that of other road users
  9. Be courteous: Share the road with all and be considerate. Never rage on the road
  10. Never mix drinking and driving: Be Responsible. Do not drink while driving.”


West Bengal state Government of Union of India is in the process of starting eight trauma care centres across the geographical zone of the state on or near national and state highways and other important roads. Three of them in state medical college campus, namely, Institute of Postgraduate Medical Education and Research, Bardhaman Medical College and Hospital, and North Bengal Medical College and Hospital; rest five will be located in Kharagpur, Asansol, Islampur, Singur, and Amtala.[41]

Steps needed to be taken to improve road safety

There is an urgent need for placing emergency medical services on roads in general and highways in particular as even in metros there is a paucity of provision for prehospital care even at the major intersections even in metro cities in India.

Role of civilians

It is really strange that the general populations, who are the main victim of road traffic accidents, are not following the safety measures and already devised rules. It is a common sight to see people breaking traffic lights, driving while drunk, and driving recklessly at high speeds. People wear seat belts as if they have been awarded punishment. It is needless to say that without the responsible and active involvement of the general populations, it is not possible to achieve success in road safety. Since childhood road safety precautions have to be inculcated among our future generation regarding the use of “zebra crossing” and to strictly follow pedestrian crossing signals along with directions from traffic officials. Furthermore, citizens need to be sensitized not to park vehicles at roadside obstructing smooth traffic flow as well as causing inconvenience to commuters and fellow traffic. Road safety for the children and adolescents can be upgraded with an updated internalization of risk factors and concrete interventional strategies. Leaving the children alone outside homes or left with the care of near peers has contributed to the occurrence of injuries. Not only sensitizing the parents and caregivers on precautions while rearing children but also capacity building is the call of the day. Injury prevention programs are most likely to be effective to reduce frequency of injuries if they reach who experience the most injuries. To have this on ground reality, not only trained and dedicated workforce to be groomed but also regular drill as well as updating of skill and competency is needed by the government in power with their positive willpower to use the administrative machinery.[12]

Regular health check-up of drivers

Preemployment and regular check-up of all drivers can reduce RTIs. Comorbidities such as epilepsy also need attention. All interventions need to be completely researched in advance to be standard guidelines for everyone. The research process is so that we can be sure they work in given sociodemographic-economic milieu; they work better than, available at the moment, known to be safer alternatives. At first, interventions are developed and tested inside laboratories. For safety reasons, experimental methods like simulation exercises for infrastructure development of road engineering with micro plans of lighting, skid-proof roads, and two-way traffic. To address this significant public health problem, we need to relocate research efforts. Experts in this field have recommended research guidelines to standardize case definition and data reporting parameters on TBI with cumulative data.[42],[43]

Simulation exercises

Recent research has inroads to remarkable advances in the highway safety knowledge. Yet, professionals are not well trained to advocate and apply available safety tools for successful highway design outcome. Tools do not create the road safety; trained professionals do while training cannot be accomplished with a short road safety course which requires a deep understanding of principles of highway and traffic engineering that may or may not be any formal course. Higher Education Master Courses in a joint effort between EU and Russian Universities are a good start to implement a new curriculum program in Highway Design and Management, with focus on road safety.[44]

National injury prevention program

Road safety education and policy development should be a part of a comprehensive National Injury Prevention program in any country in general and India in particular with reported huge burden of road traffic injuries. The goals of this program will be to develop and implement effective injury prevention and education strategies across our multilingual and multicultural country with wide geographical variations among the states with an emphasis on people's participation in a decentralized manner.

WHO Member States encompassed specific goal on road safety in the SDG 3.6. The World Health Assembly (WHA) Resolution 69.7, May 2016, adapted to continue facilitating a transparent, sustainable process on key risk factors and service delivery mechanisms to reduce road traffic fatalities and injuries. In response to the WHA 69.7, the process which the WHO Secretariat has followed to develop the global performance targets from September 2016 to November 2017 through meeting with technical road safety experts to discuss candidate global targets for the prevention and control of road traffic injuries, associated indicators and the mechanism for collecting this information to generate a “zero draft” (version dated 31 October 2016) WHO Discussion Paper. Then, through the UNECE's Working Party 29 and the meeting of the UN Road Safety Collaboration, the WHO Secretariat published a first revision of the Discussion Paper. After the informal member State consultations with the UNECE's Inland Transport Committee and UNECE's Working Party, the WHO Secretariat published a second revision of the Discussion Paper and later on finalized a comprehensive set of 12 global road safety targets.[45]

Where we need to reach

There is a need to inculcate the concept of best practices in road safety education from primary school children with outcomes of interest focused on appropriate road safety knowledge and attitudes; few addressed behavior. Researchers highlighted importance of collaboration of major stakeholders, including parents and the wider community, in planning and coordination.[39] There is a need of bringing forth basic factors again and again, i.e., speed, drink driving, helmet use, seat belt, and child restraint as they are largely avoidable and these are essentially under personal control and no one else is responsible in their observance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Ethical conduct of research

The researchers are committed to advancing and safeguarding the highest academic and ethical standards in all parts of this systematic review following 'Helsinki declaration'.



 
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