What's New in Critical Illness and Injury Science? We must lead by hope…

Napoleon claimed that doctors would have more to answer for in heaven than would generals. Two manuscripts in this issue remind me that this may be truer now than it ever was. It has become very easy to sit in a comfortable world of benchmarks and data and a robust trauma and health care system and be very happy with where we are. Occasionally we need to step back and realize there is more to our world than what we see outside our windows.

Road deaths in India are estimated to be greater than 200,000 per year, nearly 20 deaths per 100,000 population.[1] In Iran, this number is as high as 30 deaths per 100,000 people. In countries where transportation is generally not high-speed highways, these deaths are occurring in the cities to those walking and using motorized two-wheeled vehicles. The numbers are astounding. But this recalls the situation in 1966 in the United States, when the document Accidental Death and Disability: the Neglected Disease of Modern Society,[2] was published. The road associated mortality rate in the U.S. was 25 deaths per 100,000 population fifty years ago – perhaps for different reasons, and different mechanisms, but no less concerning.

This is the importance of these papers – until we have information and data we cannot intervene in a public health manner. It is the vivid truth of trauma that the only treatment for the disease is prevention and early intervention. And the only way we can implement change is to know the target of our aim. The simple act of gathering data about our patients and attempting to apply interventions makes a difference. In the first of these two papers, the authors have essentially created a registry to try to define who their patients are and what is happening.[3] In a north Indian city (Lucknow) with a population approaching 3 million, 66.4% of their injuries were due to road events, with a staggering 24.1% inpatient mortality. This did not shock me until I read deeper and realized, for patients brought directly to the trauma center the average time from injury was 22 hours. I actually had to pause and put down the paper. Nothing I do in my trauma center is applicable to the surgeons, nurses, and healthcare team working in this city. That is hyperbole, but it is how I felt at the moment. The average transport time for a patient to my trauma center is 30 minutes, and that is from notification of the ambulance to arrival in my trauma bay. The vast majority of patients who arrive at King George Medical University trauma center have survived the test of time, but clearly arrive already far down the road of the consequences of their injuries. This is portrayed sharply in their injury breakdown – with only 1.8% abdominal injuries; these constitute a third of what I see. The blunt reality is, patients with intra-abdominal injuries died before these caregivers had a chance to intervene, or never presented to the trauma center. Only 49 patients were brought via ambulances, out of thousands. The mortality rate at their facility is clearly a public health problem, and not a problem with care. This is a situation confirmed by others in India,[4,5] and can only be identified by gathering clear data – in essence, creating a patient registry.

In the second paper, Moradi et al. analyze the patterns of road deaths in Tehran – essentially taking the concept one step further, to begin to identify where prevention or intervention should occur.[6] This was a traffic study to identify where the most injuries occurred and to decide if factors in those areas could be identified contributing to events. So, if there are many road injuries in a region, analyzing where they happen could be the first move to changing the pattern. Again, I was struck – my base assumptions are wrong – it is not the level of care, but rather the availability of data and understanding that is the problem. I can go on the Internet now, search for areas of injury, and in moments know the worst intersections for injury and crash in my city. This is data I take for granted. In Iran, this information is not supplied by government safety agencies, but is being gathered and analyzed by those who will have to deal with the aftermath of injury. This was also the case 50 years ago in my country, but we have forgotten.

My first house had an upstairs that was once an open-air sleeping loft – a place to rest that allowed a cooling breeze in the hot summers of the central valley of California. It had since been enclosed, heated, cooled, and controlled. In Lucknow, a significant number of rural injuries were from falls while sleeping on the roof. My grandparents slept outside in the summers in Iowa due to no electricity and the heat. Our worlds are not so different, but the needs of now are divergent. More valuable is to help each other to learn what is right for the present. The more we know about the current state of injury and emergency transport in these countries, the more it can be helped. Ambulances are not technologic marvels, but the organization of them is costly and time consuming, and the people must want to use them. When Dominique-Jean Larrey implemented ambulances in Napoleon's army it was 1792, but it was not until the 1970s organized ambulance services appeared in the U.S. Perhaps we can help one-another to jumpstart this evolution rather than waiting for the gradual passage of time and cultural change.

I am fairly certain that the medical professionals of Lucknow and Tehran would say that learning care and algorithms for patients is necessary, and I doubt any of them would deny the benefits of programs such as Advanced Trauma Life Support^® But what they are showing us is a desire to go after the source of their problems, and to create a burning platform for change. It is our duty, as their partners to help them to accomplish this and to help them find solutions that fit their world, not ours. One example of this is the great work out of Cape Town to create a registry using technology – decreasing the need for trained individuals and manpower that can be used elsewhere.[7] This is a collaboration with researchers in North America, leveraging technology to make a difference across the globe. It is innovative and collaborative efforts like this that can help us to define what our problems are and to help our partners move forward in ways that are better and faster than our own path.

Accidental Death and Disability: The Neglected Disease of Modern Society,[2] identified and made recommendations to improve the care of seriously injured patients. The paper proposed strong government leadership, and clearly identified that the gained productivity would make up for the cost. In India, road injury and death costs up to 3% of their GDP every year, over 50 billion U.S. Dollars – enough to make up for a significant proportion of the cost of prevention and intervention.[8] In 1966 several recommendations were put forth: (1) Creation of established standards for ambulance services; (2) the use of radio communications technology for timely dispatch; 3) creation of specialists in immediate care; (4) creation of registries of valid and reliable data; (5) investment in prevention of injury through sponsored research, public education, or government regulation; and (6) the creation of a budget for injury research.[9] Much of this was accomplished in the succeeding five decades, but the research budget never truly materialized. This has not stopped the production of science and the push of individuals to make change through study. This is why I applaud the researchers presented here and all those working around the world. Only through their efforts and by learning from one-another can we avoid past mistakes and more importantly save the lives of those most at risk. Perhaps then we will have less for which to answer.