Delivering Trauma Care to Developing Countries
Trauma in all its manifestations and great variety of causes is responsible for approximately 5 million deaths a year globally and many of these occur in developing countries. The Primary Trauma Care Foundation provides courses to doctors in primary trauma care (PTC) at minimal cost and empowers developing countries to train their own staff. Pakistan and Gaza are but two examples of the potential for PTC to save lives.
Various courses have been developed to teach doctors how to deal with the immediate effects of trauma. All depend on acquiring a systematic approach, evaluating and dealing with the most life-threatening injuries first. Hence the emphasis on first ensuring that the airway is patent, then assessing breathing and circulation before proceeding to evaluate neurological, abdominal and bony injuries.
My interest in this subject started in 2003 when my orthopaedic friend, John Beavis, announced that he wanted to bring better trauma care to the tribal areas of the North West Frontier Province of Pakistan. I knew the Professor of Surgery in Peshawar, Mohammed Kabir, and offered to come with him during his assessment visit. We met with enthusiasm for the project from the local doctors, and after returning home signed up for the Advanced Trauma Life Support (ATLS) course at UCH. Thankfully we both passed, but in the process we realised that ATLS was not appropriate for a developing country like Pakistan. Fortuitously, I was then introduced to Douglas Wilkinson, Consultant in Intensive Care at the John Radcliffe Hospital in Oxford, who founded the Primary Trauma Care (PTC) Foundation in 1997 and it became obvious from talking to him and reviewing the training manual that PTC was a far better option for Pakistan than ATLS.
So in 2004 we took a group of six instructors to Peshawar for the first PTC course. Professor Kabir had carefully selected the candidates from the staff of the four local medical schools. After the initial two-day training course, an instructors course was held and then further training courses were held in each of the medical schools, so that by the time of our departure over 100 doctors had been trained in PTC in Peshawar.
The subsequent success of PTC in Pakistan was fascinating to observe. With support from UK instructors, courses were soon requested and held in Rawalpindi, Karachi and Lahore and subsequently taken to surrounding district hospitals. Then in 2005, as an example of the international role played by PTC, the Sindh group took a course to Delhi, this being an unusual example of medical collaboration between India and Pakistan.
As a result of my involvement with this, Douglas Wilkinson asked me to become the Patron of the Primary Trauma Care Foundation, a position I have been proud to hold since 2006. Courses in PTC have now been held in over 40 countries and the training manual translated into 14 languages. Doctors in these countries, whether practising in cities or rural areas, are now better equipped to provide immediate care to seriously injured patients. The policy we have followed can be summarised as follows:
1. Teach a straightforward system of saving lives based on the same principles as ATLS but flexible enough to be adapted to local circumstances.
2. Provide training courses at minimal cost – all our instructors are volunteers – and allow countries to use our training manual and material and adapt these to their own needs.
3. Empower countries to train their own staff in trauma management and motivate them to develop strategies of trauma prevention.
One of the more recent and very worthwhile projects came again from John Beavis, who suggested in 2008 that we should explore the possibility of taking the PTC courses to Gaza. However, it was not until August 2009 that we were able to gain entry to Gaza under the auspices of Medical Aid for Palestinians (MAP). On arrival we were dismayed to see the extensive damage that had been inflicted on public buildings, schools, hospitals, Mosques, private homes and apartments as a result of the Israeli invasion of 6 months previously. More than 1400 Gazans had been killed, many of them women and children, and there had been thousands of serious injuries that had swamped the medical facilities.
With willing help from the local MAP office in Gaza City, he and I were able to visit over a dozen hospitals throughout the Strip and confirm during our interviews with local doctors that they would welcome participating in trauma courses such as we described. MAP generously agreed to fund these and so in November 2009 we returned with a team of volunteers and held the first two training courses followed by an instructor’s course at Al Shifa Hospital in Gaza City. There we were provided with good facilities and excellent support from Dr. Nasser abu Shabaan and his team.
Before our return to the UK Dr. Nasser generously agreed to set up and chair a committee that would be responsible for overseeing the propagation of PTC course throughout Gaza. Three months later two of our team returned to participate in the first training courses run by the locally trained instructors.
Subsequent courses have been a great success and by now many hundreds of doctors and nurses have been trained in Primary Trauma Care in Gaza. During my last visit in November 2010 I was delighted to observe 5th year medical students from the Islamic University enjoying the challenge of taking the course at Al Shifa Hospital. All of us associated with the project have come to admire the courage and fortitude with which the Gazans are facing the aftermath of the invasion and dealing with the continuing blockade by Israel which affects all aspects of their lives. Many good friendships have been made and these in turn have led to other medical projects being started in Gaza that we hope will be of equal benefit. These are but two examples of what the Primary Trauma Care Foundation is bringing to poorer and developing countries.
Sir Terence English KBE is a retired cardiac surgeon, having performed Britain’s first successful heart transplant in 1979. Sir Terence was elected President of the Royal College of Surgeons of England 1989-1992, and President of the British Medical Association in 1995-1996.