Trauma Systems: Development Strategies in Emerging Nations

Abstract

Trauma is the leading cause of death and disability. Numerous studies have shown that trauma systems, which provide an organized approach to acutely injured patients from primary to advanced care, improve outcomes. The aim of the thesis is to look at various aspects of trauma systems in two emerging nations: Saudi Arabia, a high-income country, and South Africa, a middle-income country, particularly in the areas of prehospital, in-hospital, and rehabilitation. Part 1 describes the background and development of trauma systems in two developing nations: South Africa and Saudi Arabia. Chapter 2 discusses the historical and contemporary contexts in which trauma systems operate in both countries. Chapter 3 narrates the recent transformation of Saudi healthcare which laid the foundation for trauma system development in the Kingdom. Chapter 4 portrays the development of the Saudi Arabian trauma system. Part 2 describes the prehospital portion of trauma systems. Chapter 5 analyzes the effects of delays in emergency medical service responses on trauma outcomes. Chapter 6 explains that the administration of tranexamic acid in a hospital setting for bleeding trauma patients is often not feasible due to the longer prehospital time, especially in lower- and middle-income countries. In-hospital trauma management starts in the emergency department (ED). Part 3 concentrates on the improvement of trauma management in the ED. Chapter 7 emphasizes regular trauma resuscitation training for healthcare professionals managing trauma patients. Chapter 8 discusses the importance of the shock index—a simple calculation based on initial vital signs—as a screening tool in ED. Part 4 details various aspects of the management of admitted trauma patients. Chapter 9 describes the selective nonoperative management of liver gunshot injuries. Chapter 10 is a pilot randomized controlled trial on laparoscopy versus clinical follow-up to detect occult diaphragm injuries following left-sided thoracoabdominal stab wounds. Chapter 11 explains how to deal with lethal penetrating trauma to the mediastinal vessels, and Chapter 12 outlines how to diagnose and manage blunt cerebrovascular injury. Part 5 is a report on the complications of in-hospital trauma management. Chapter 13 describes surgical site infections following trauma laparotomy, and Chapter 14 describes the incidence and nature of venous thromboembolism in polytrauma patients. Part 6 describes the outcomes of in-hospital trauma management. Chapter 15 looks at the effects of a delay in surgery after scheduling, based on the emergency surgery triage system. Chapter 16 analyzes the outcomes of damage-control surgeries. Chapter 17 compares trauma management between two major trauma services in Riyadh, Saudi Arabia, and Melbourne, Australia. Finally, in Part 7, the rehabilitation portion of the trauma system is described. Chapter 18 emphasizes the early incorporation of acute intensive trauma rehabilitation into trauma programs. Chapter 19 summarizes the findings presented in this thesis and presents a general discussion and future perspectives. The future perspective focuses on improvement in certain areas of trauma systems in both South Africa and Saudi Arabia, implementing a national trauma database, research and development, and trauma quality improvements in care processes and outcomes.