Pre-Hospital Care of the Injured in South Western Nigeria: A Hospital Based Study of Four Tertiary Level Hospitals in Three States

Abstract

Pre-hospital care in developing worlds has been found to be grossly deficient compared to high income countries. The pre-hospital care given to road accident victims attending the casualty departments of four tertiary level hospitals in South Western Nigeria was assessed using a one-page pro-forma. 1996 patients with injuries from road crashes were seen in the hospitals, only 172 had any form of pre-hospital care, just 160 were transported in ambulances and none had any form of organized pre-hospital care. The mean arrival time in the hospital after crashes was 93.6 minutes and there was a high rate (29.5%) of inter-hospital referral. For every Revised Trauma Score (RTS), the Probability of survival (Ps) of the patients was higher than the Ps of patients from high income countries.

While injury is a major health problem all over the world (Murray et al., 1997; Mock et al., 2001), far less attention is directed towards better understanding of the problem, its prevention or the improvement of trauma management in the low-income countries of Africa and Asia compared to the high-income countries of America and Europe (Mock et al., 2001; Majid et al., 2001; Kobusingye et al., 2001). This may be the reason why more than 2/3 of all trauma related deaths occur in the developing world (Murray et al., 1997). If such dismal outcome in the developing world is to improve, then accurate information about the present system needs to be obtained (Mock et al., 2001; Kobusingye et al., 2001; Kobusingye et al., 2001). Such information will be useful in making correct and informed decisions about how to attack the problem of trauma and its management.

Osun, Ondo, and Kwara States are contiguous states in the south-western Nigeria with a combined population of about 8 million (1991 census). They are four tertiary level hospitals in the States. These hospitals function similarly to the level 1 trauma centre of the American College of Surgeon (ACS) classification in the United States of America (1997). The four hospitals are: LAUTECH Teaching Hospital (LTH) Osogbo, Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC) Ile-Ife, Federal Medical Centre (FMC) Owo and University of Ilorin Teaching Hospital (UITH) Ilorin. All of them have 24 hours casualty departments with both Junior and Senior Resident Surgeon coverage.

Like so many African countries, Nigeria has no systematic pre-hospital emergency care, as such; patients with injuries are brought to the hospitals by bystanders, fellow passengers or law-enforcement agents using any form of transportation at hand (Kobusingye et al., 2001).

The present study was designed to identify the level of pre-hospital care in Kwara, Ondo and Osun states of Nigeria, identify the relationship between injury-treatment interval and outcome in the casualty, and to compare the probability of survival (Ps) in Casualty Departments from crash injuries in South Western Nigeria with published Ps from high income countries using the Revised Trauma Score (RTS).

METHOD

A one-page pro-forma was designed to be completed in the casualty department for each motor vehicle crash patient by the surgical resident on call. Information was obtained from the patients and the persons who brought them to the hospital. Such information include demographic data, time and date of injury, time and date of arrival in the hospital, mechanism of road accident, type of vehicle involved in the accidents, number of passengers in the vehicle, number injured, number dead, the type of pre-hospital care and the mode of transportation to the hospital. The vital signs, Glasgow Coma Scale (GCS) and injuries sustained were assessed and recorded by the resident doctor. The Revised Trauma Score was calculated from the vital signs and GCS. The outcome in the casualty was categorized accordingly; discharged home, dead, transferred to the ward, referred to other hospitals, or discharged Against Medical Advise (DAMA) when patient refused hospital treatment.

STATISTICAL ANALYSIS

The RTS was calculated using the syntax function of SPSS Version 11. The significance of continuous variables was assessed by univariate ANOVA while the χ²-test was used for categorical variables. A level of significance of 0.05 was applied to all tests.

RESULT

One thousand nine hundred and ninety six road crash victims were seen at the casualty departments of the four hospitals within the study period. There were 1600 males and 436 females. The mean age was 30.3±13.3 years. It ranged from 2 to 80 years.

ACCIDENT PARAMETRES

Most accidents occurred on urban roads (49.1%) closely followed by highways (46.3%) (Table 1). Cars either private or taxis accounted for 41.88% of the accidents while 31.06% were caused by commercial buses. Six hundred and eighty four (34.3%) patients had their injuries in collisions between motor vehicles, 408 (20.4%) in single vehicle crashes, 380 (19.0%) in motorcycle crashes and 364 (18.2%) pedestrian accidents. Sixty eight (3.4%) sustained their injuries in burst-tire crashes.

Table 1.

Accident site by vehicle type.

Accident site	Cars	Buses	Motorcycle	Trucks	Others	Total
Urban	456	252	236	36		980 (49.1)
Highways	352	352	76	112	32	924 (46.3)
Rural	28	16	44	4		92 (4.6)
Total	836 (41.88)	620 (31.06)	356 (17.84)	152 (7.62)	32 (1.60)	1996 (100)

Figures in brackets are percentages of the total.

INJURY PARAMETERS: twelve thousand and forty persons were involved in the accidents with 1,292 (10.7%) immediate fatalities. Eighty thousand three hundred and fifty six (69.4%) persons were injured, 1996 (23.9%) of which were seen at the casualty of the four hospitals.

PRE-HOSPITAL CARE

One hundred and seventy two (8.6%) of the patients were given some form of pre-hospital care by bystanders. Seventeen patients had their wounds irrigated with water, wound coverage by clothing materials was accomplished in 10 patients, and 5 patients had their fractures splinted with wooden bars while 4 patients apiece were given water to drink or food to eat. The rest were brought to the hospital without any form of treatment before arrival at the casualty department of the participating hospitals.

TRANSPORTATION

One hundred and sixty (8.0%) patients were transported to the hospitals in ambulances none of which were manned by trained health workers. Table 2 itemizes how the patients were transported to the hospitals.

Table 2.

Mode of transportation to the hospitals

Mode of transportation	Frequency	Percent
Four-door cars	884	44.4
Buses	468	23.4
Two-door cars	168	8.4
Ambulance	160	8.0
Pick-up	112	5.6
Trucks	104	5.2
Motorcycles	76	3.8
Police vehicles	16	0.8
Walked	8	.4
Total	1996	100.0

INTERVAL BETWEEN INJURY AND PRESENTATION OF THE CASUALTY

One thousand and four hundred and twelve (70.7%) patients were brought directly to the hospitals, 416 (29.5%) of these arrived within 30 minutes while another 392 (27.5%) arrived between 30 minutes and an hour. The overall mean arrival time for all patients was 93.6 minutes. For those who died in the casualty, the mean arrival time was 49.8 minutes while it was 96.0 minutes for those who survived.

TREATMENT AT OTHER HOSPITALS

Five hundred and eighty four (29.3%) patients were referred from other hospitals, 300(51.3%) of these were from private hospitals, 208 (35.6%) from secondary level government hospitals and 64 (11.0%) from mission funded hospitals and 12 (2.1%) from traditional care centers. A significantly higher proportion of those who had their initial treatment in other hospitals died in the casualty compared to those who were brought directly to the hospitals where the study took place.

REVISED TRAUMA SCORE (RTS)

The mean RTS for the patients who died in the casualty was 5.0875 ± 1.6254 SD which was significantly lower than the 7.6744 ± 0.6083 SD for the survivors. The probability of survival (Ps) is less than 0.5 in patients with RTS of 6 or less (Table 3) while the Ps of the patients in our study is less than the estimate given by Champion et al for every RTS score.

Table 3.

RTS of the patients.

RTS	Total	Survived	PS of present study	Ps in literature
0	0	0	0	0.027
1	0	0	0	0.071
2	2	0	0	0.172
3	5	0	0	0.361
4	15	6	0.400	0.605
5	13	6	0.462	0.807
6	18	9	0.500	0.919
7	15	14	0.933	0.969
7.84	431	425	0.988	0.988

OUTCOME IN THE CASUALTY

Eight hundred and eighty four (44.3%) patients were transferred to the ward, 852 (42.7%) were discharged home, 156 (7.8%) died, 88 (4.4%) took their discharge against medical advice (DAMA) and 16 (0.8%) were referred to other hospitals.

DISCUSSION

It is not surprising that not one of the patients in our study had organized pre-hospital management. This is in keeping with other studies from the African continent (Kobusingye et al., 2002; Mock et al., 1998). But what is of greater concern is that some of the so-called treatments given by the bystanders to the patients in the pre-hospital setting were inappropriate and dangerous. When appropriately trained, bystanders may offer useful life saving interventions to the accident victim and are not likely to offer inappropriate or potentially dangerous treatment to accident victims (Lockey, 2001).

Of further concern is that only 29.5% of the patients arrived in the hospital within 30 minutes of their injuries. The average arrival time was 93.6 minutes. Even though this falls within the time frame of most studies reported from Africa (Andrew et al., 1999), it is grossly longer than those reported from high income countries (Nichols et al., 1998; Osvaldo et al., 2002). Surprisingly, those who died in casualty actually had a lower mean arrival time than survivors. One explanation for this could be that the injuries of those who died might have looked so frightening to the lay people who brought the patients in that, they were transported with all haste to the hospital. A similar finding was reported in a recent study in Uganda (Kobusingye et al., 2002).

Results also showed that more than 90% of the victims arrived in the hospital in makeshift transportation and some of the vehicles used could have worsened the patients’ injuries. Thus transporting a patient with vertebral injury in a small vehicle like a two-door hatchback car has the potential of worsening such injuries. The proportion of cases that were referred from other hospitals (29.3%) is comparable to what was reported in a recent study in Iran (Majid et al., 2001). This high rate may be due to the absence of a functioning pre hospital triage system in Nigeria.

Furthermore, a significantly higher proportion of those who were referred from other hospitals died in the casualty compared to those who were transported directly to the tertiary hospitals. This may be indicative of the deleterious effect of delay in arrival in the tertiary hospitals on the outcome (even though there was no significant difference in the mean RTS of the two groups of patients).

Many reasons can be adduced to the relatively low proportion (23.9%) of injured patients who presented in our hospitals. One is the low patronage of formal health care facilities in Africa. A Ghanaian community based study found only 31% of injured patients received formal medical care (Mock et al., 1997). Still other victims may have been taken to other hospitals, traditional care givers, religious homes or simply went home (Kobusingye et al., 2001). The RTS has been found to be a very sensitive and strong predictor of survival (Mohammed et al., 1999). Findings in our study agree with this. However we found that at every RTS level, the probability of survival of patients in our patients is lower than those reported from patients with corresponding score in studies reported from high income countries (Champion et al., 1989). It is of grave concern that up to 60% of patients with RTS between 0 and 6 died in the casualty. Thus there is a great need to urgently review the trauma care system in Nigeria. But simply importing techniques from high income countries will not work (Mock, 2001). Rather, there is a need for better injury surveillance and the establishment of hospital and community based trauma registries as a first step in improving trauma care in our environment (Majid et al., 2001; Kobusingye et al., 2001; mock et al., 1998).

LIMITATIONS

This is a hospital based study; as such, it suffers from the well known limitations of such studies (Kobusingye et al., 2001). Also, the estimation of the number of occupants of vehicles who died or were injured as well as the total number of occupants were based on what was reported by the lay people who brought the patient to the hospital. Only on few occasions were such information obtained from law-enforcement agent.