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THE STATE OF TRAUMA AND EMERGENCY MEDICAL
SERVICES
JAMAICA
Hugh M. Wong DM
Kingston Public HospitalJamaica
The Reality of my Job
Introduction• As in most developing and developed countries Traumatic
Injury is of great concern• High rates of traumatic injury has long been a feature of the
Jamaican reality• Trauma is a leading cause of death and disability in Jamaica
with significant adverse impact on the overall economy and on the psyche of the country.
• Reflected in the reputation of the nation as evidenced by the need for our current meeting
• Primary prevention as in any disease of public health significance is the key to reduction of the incidence of that condition
• However research has demonstrated that better organized and effective trauma care systems increase survival rates and reduce long term disability
Effects of Trauma
FamilyCommunity
• Societal Toll
Medical Costs • Economic
Premature Death and Disability
• Loss of Productivity
Contributory Factors
TraumaAlcohol Abuse
Intentional Injury
Hazardous environments
and workplaces
Poorly designed and maintained
roads
Overburdened Health care
Infrastructure
Lack of efficient Emergency response systems
WHO; Pre-hospital Trauma care systems 2005
The Current State of Trauma in
JamaicaLocal-Kingston Public Hospital
National-Hospital Monthly Statistical Reports
Accident & Emergency Department• A small department• Four treatment cubicles• Only one cubicle fully equipped as a Resuscitation
Bay• Two doctors assigned per shift to the see Level I & II
patients Medical and Surgical• Total doctors per shift maximally 9• Need to mobilize staff from other areas to assist in
patient care when necessary
Trauma Bay
TOTAL PATIENT VISITS A&E 2012MONTH REG &SEEN ADMITTEDJANUARY 6269 2038FEBRUARY 5609 1813MARCH 6112 1986APRIL 5723 1694MAY 6215 1984JUNE 6222 1960JULY 5842 1972AUGUST 6208 1905SEPTEMBER 6562 2103OCTOBER 6675 2180NOVEMBER 6391 1953DECEMBER 6287 2061
74110 23599
TRAUMA VISITSMONTH TOTAL VISITSJANUARY 183
FEBRUARY 152
MARCH 159
APRIL 161
MAY 244
JUNE 150
JULY 179
AUGUST 147
SEPTEMBER 161
OCTOBER 186
NOVEMBER 183
DECEMBER 253
2158
Trauma Mechanism
63%
21%
4%
5%5% 2%
MVAGSWSWFALLSBLUNTLACERATIONSBURNSSEXUAL ASSAULT
Trauma Visits
January February March April May June July August September October NovemberDecember0
20
40
60
80
100
120
140
160
180
200
130
120 121116
172
117
138
114 117
146141
177
53
3238
45
72
3341
33
4440 42
76
MalesFemales
Trauma Visits by Gender
January
Febru
ary
Marc
hApril
May
June
July
August
September
October
November
December
020406080
100120140160180200
FEMALESMALES
Incidence by Age and Gender
<12 12-15 yrs
16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 76-80 81-85 86-90 91-95 96-100
0
50
100
150
200
250
300
350
Males
Females
Incidence
Age
Time of Day
0-4 am 4-8 am 8-12 md 12-4 pm 4-8 pm 8-12 pm0
50
100
150
200
250
300
350
400
450
500
Incidence
Trauma Cases by Day of Week
Sunday
Monday
Tuesday
Wednesd
ay
Thursday
Friday
Satu
rday
0
50
100
150
200
250
300
350
Trauma Visits
Trauma as % of total Attendance
3%
97%
TRAUMA NONTRAUMA
TRAUMA ADMISSIONS AS % OF TOTAL ADMISSIONS
758; 3%
23599; 97%
TRAUMA ADMISSIONS TOTAL ADMISSIONS
Patients requiring immediate surgery as % of critical visits
7%
93%
Directly to OTTrauma visits
Patients Dying from Traumatic Injury in A&E
3%
97%
Died in A&ETrauma visit total
Deaths in the A&E Department
GSW MVA Stab Wound
Other0
5
10
15
20
25
30
35
40
Male
Female
Deaths Due to TraumaPrior to Accident and Emergency Department
GSW MVA Stab Wounds
Other0
100
200
300
400
500
600
Males
Females
Not Reported In MOHE data.
ICU Admissions by Intent
GSW Stab Wound
Blunt MVA Fall Burn Blast0
5
10
15
20
25
30
Intentional
Unintentional
Num
ber o
f Pati
ents
Intentional Unintentional
Total ICU Length of Stay by Intent
GSW Stab Wounds
Blunt MVA Fall Burns Blast0
50
100
150
200
250
300
350
400
450
500Intentional Unintentional
Day
s
• Kingston Public Hospital sees a low percentage of major trauma relative to other conditions• Medical and Non-traumatic conditions
pre-dominate
• SO WHY ARE WE HERE??
Nationally -HMSR Data
Hospitals By DesignationType A (Level 1) Type B (Level 2) Type C (Level 3) SpecialistKingston Public Hospital Spanish Town Hospital Princess Margaret
HospitalBellevue
Cornwall Regional Hospital
Savannah-la-MarHospital
Linstead Public Hospital Victoria Jubilee
University Hospital of the West Indies
St. Ann’s Bay Hospital Annotto Bay Hospital Bustamante Hospital
Mandeville Regional Hospital
Port Antonio Hospital National Chest Hospital
Port Maria Hospital Hope Institute
Falmouth Hospital Mona Rehabilitation
Lionel Town Hospital
Noel Holmes Hospital
Percy Junor Hospital
Black River Hospital
May Pen Hospital
Intentional Trauma
REGION Stab Wounds Gun ShotBlunt Injury
Sexual Assault
Intentional Lacerations Other
SERHA 1058 258 1780 539 501 1299
NERHA 551 71 2237 278 1171 2021
WRHA 574 257 2661 421 1393 1101
SRHA 221 97 1420 243 1497 883
2404 683 8098 1481 4562 5304
Intentional Trauma by Region
WRHA SRHA NERHA SERHA0
500
1000
1500
2000
2500
3000
Stab WoundsGunshotBluntSexual AssaultLacerationOther
Unintentional TraumaREGION MVC
ACCIDENTAL LACERATIONS
UNINTENTIONAL BURNS POISONING BITES DROWNING FALLS
SERHA 2750 4327 523 395 1427 9 5755
NERHA 2216 4068 329 280 2137 9 4556
WRHA 3388 3126 419 172 1237 9 4806
SRHA 1930 3181 289 103 1063 4 3074
10284 14702 1560 950 5864 31 18191
Unintentional Trauma by Region
WRHA SRHA NERHA SERHA0
1000
2000
3000
4000
5000
6000
7000
MVCLACERATIONSBURNSPOISONINGBITESFALLSDROWNING
Effects of Trauma
COSTPREVENTABLE DEATHS AND DISABILITYLOSS OF PRODUCTIVITYA CAUSE OF INCREASED MORBIDITY AND
MORTALITY IN NONTRAUMATIC CASES
Fatal, Serious and Slight Injuries
Ward et al. West Indian Med J 2009;58(5): 446
Cost of Interpersonal Violence
Ward et al. West Indian Med J 2009;58(5): 446
2.1Billion
Cost of Motor Vehicle Crashes• In 1996, the cost to the Health Sector was
approximately US$518 million. • This cost represented 13.27% of the revised
budgetary expenditure for secondary and tertiary care in 1996/1997.
• It also represented 7.87% of the revised budget of the Ministry of Health for 1996 /1997, which was J$5.33 billion.
National Road Safety Policy Doc. 2004
ADDRESSING THE PROBLEM
ResearchPre Hospital Emergency Medical
ServicesCASEVACEmergency Medicine Postgraduate
ProgramBLS,ACLS,ATLS TrainingMCM, MCI training
Research
• Numerous papers on trauma and trauma care systems from the UHWI
1. The Evolution of Emergency Medicine in Jamaica -EW Williams1, J Williams-Johnson1, AH McDonald1, S French1, R Hutson1, P Singh1, J Sadock2, R Butchey1,M Ellis1, C Thompson1, K Espinosa1Trauma registry at the UHWI
2. Trauma in the Developing World: The Jamaican Experience : JM Plummer, D Ferron-Boothe, N Meeks-Aitken, AH McDonald
3. Emergency department physician training in Jamaica: a national public hospital survey :Ivor W Crandon†1, Hyacinth E Harding†1, Shamir O Cawich*†2,Eric W Williams†3 and Jean Williams-Johnson†3
4. Non-fatal violence-related injuries in Kingston, Jamaica: a preventable drain on resources.
Zahoori, Gordon,Wilks,Ashley,Forrester
5. Trauma Admissions to the ICU of The University Hospital of the West Indies, Kingston, Jamaica : Mitchell, Scarlett, Amata
International Courses
• BLS and ACLS• Formally started in 1998• MOH and Heart Foundation of Jamaica continuing
training• Mandate to certify all doctors and nurses working in
high acuity areas
• ATLS• First held in May 2001• Jamaica Chapter of the American College of Surgeons
Disaster Management
•PAHO•World cup cricket 2007
• Mass Casualty Management• Incident Command Systems• Emergency Care and Treatment
Emergency Medicine
• Four year residency program in EM started at UWI 1996
• Follows similar program in Barbados in 1990• Emergency rooms in all Type A and B hospitals now
staffed by at least 1 Emergency Physician• Thirty seven graduates since 1996• Graduates working all over the Caribbean• EM training for Nurses in 1995
Emergency Medical Services• History• Organization• Current Status• Statistics
Emergency Medical Services
• Jamaica has a long history of ambulances attached to hospitals and almshouses from the 1930’s
• Hence the Jamaican public has a long established expectation of government provided medical transportation
• The GOJ since the 1980’s has endeavored to establish a Pre-Hospital Emergency Medical Service
• In 1996 a Pilot project was launched in the Western Regional Health Authority dubbed “Phase 1”
EMS Phase 1
• Joint Service partnership between the Jamaica Fire Brigade(JFB) and the Ministry of Health(MOH)
• JFB• Personnel
• MOH• Training• Equipment
• Ambulances• Disposables
• Technical and Clinical Supervision• Financing?
• 1996 EMS teams operating out of Fire Stations• Sav-La-Mar• Lucea• Montego Bay• Negril
• 2006• Linstead* * Phase 2
• 2007 • Falmouth
Statistics of EMS 2013
Savannah-la-Mar Negril Ironshore Lucea Linstead Falmouth Total
Motor Vehicle Accident 87 275 53 61 13 27 516
Other Trauma 106 427 38 34 2 9 616
Medical 514 639 148 254 29 77 1661
Obstetric & Gynaecology 8 29 9 6 2 1 55
Total Calls/Station 715 1370 248 355 46 114 2848
The Reality
Sav-La-Mar Negril I-Shore Lucea Linstead Falmouth Total
Calls received 715 1370 248 355 46 114 2848
Calls responded
to 444 709 174 91 2 2 1422
Ambulance downtime
(days) 153 53 71 318 365 365 1325
Call Response
Calls Responded toCalls Not Responded to
Helicopter TransportCASEVAC
• Critically ill patients with time dependent injuries ( Severe Traumatic Brain Injury)
• Service provided by the Airwing of the Jamaica Defense Force
• At a cost to the MOH.• Usually from peripheral hospitals
to the Type A Hospitals –KPH, CRH and UHWI
• Also used for CASEVAC prior in the immediate after math of Hurricanes
What is required?
• A Trauma Care system that is• Realistic• Accessible• Affordable• Sustainable• Effective• Integrated• Accepted• Legally and Ethically grounded
• No need to recreate the wheel or should we?• Build on existing infrastructure• Decide on model that will work best for
Jamaica’s current situation• Allocate resources based on an objectively
measure of need
KEY ELEMENTS
Needed• Establish a lead national agency
• Ensure regional and local support
• Local administration
• Medical Direction
• Political Support
• Financing
Current• This agency already exists
• In the areas served by EMS, the users have bought into the system, if they can access it
• The administration of EMS is currently centralized
• There is no Clinical or Administrative Medical Director. An obvious failing
• There has been little or no political or legislative support
• No dedicated source of funding
The Jamaican Model?
• What model is best for Jamaica? • National System organized and controlled by Central
Government ( MOH)• Hospital Based• Local authority based-Fire Service/ Police• Volunteer Service• Private contractual arrangements with Central of Local
Government• Hybrid system
Organization
• Regional –based on the current Regional Health Authorities• Funded from taxes –Sin Taxes, Fuel levies, Vehicle Registration fees• EMS Legislation• Training and licensing• Appropriate units for the local conditions• Maintenance-service contracts• Private/Public partnerships• Communication and dispatch –Fundamental consideration• Quality control, audit and improvement-role of Medical Director• Governance• Creation of Trauma units at each regional hospital*
What are the Benefits
• Improved patient outcomes• Reduction in patients suffering major injury• More persons recovering with less disability, able to
work, earn and pay taxes• Creation of well trained and knowledgeable persons
offering trauma care• A system that is able to respond to mass casualty
situations appropriately and effectively• Engenders confidence in travelers to the island• Enhances the Tourism product
When in need of an ambulance any vehicle will do
Whither Trauma Centers
• Kingston Public Hospital widely quoted as a “Trauma Center”
• In many ways does not meet the criteria • No facility for formal training and research• No Health Information System for Data Collection to drive research• Inadequate depth of resources and personnel• No dedicated area for trauma care• Physical configuration of the Emergency Room not appropriate for
Trauma Care e.g. No ambulance bays• General Hospital resources used for all patients
• Staff• Operating Theatre• ICU• Emergency Room
Trauma Units
• Trauma unit established at each Regional Hospital• Dedicated trauma bay• Dedicated surgical team that can be assembled at short
notice• Specialized Trauma Surgeons• Dedicated Operating Theatres• Dedicated recovery beds• Dedicated Intensive care beds ( at least 2 beds)• Go for teams located at the 2 type A regional hospitals
( KPH and CRH)• Trauma Surgeon, Anesthetist, EMT or nurse
CONCLUSION
• As in any Developing country Trauma is a major cost and hindrance to development
• Jamaica has already established in rudimentary way a Trauma Care/Pre-hospital EMS
• Development of this system has been stymied by contesting and arguably more prioritized public health concerns
• Need at this juncture to re-focus and decide on priorities
• Or we may need to change careers as other opportunities develop
There are always other business opportunities
North St
Ora
nge
St
Charles St