Developing World Trauma
Andrew Kestler, MD; Richard Fisher, MD &
Matthew Roberts, MD
University of Colorado
December 2007
Prepared as part of an education project of the
Global Health Education Consortium
and collaborating partners
Learning objectives
1.
2.
3.
4.
Quantify the global burden of trauma
Contrast unintentional vs violence-related trauma
Describe the major factors driving trauma burden
Discuss various trauma prevention strategies
Focus on road traffic accidents & collective
violence
Discuss resource-appropriate trauma management
Page 2
Learning Objectives Restated:
A Public Health Approach to Trauma
1.
2.
3.
4.
Determine the magnitude of the problem
Identify factors that increase the risk of injury and
determine which are modifiable
Assess what measures can practicably be taken to
reduce the risk
Implement the most promising interventions on
a broad scale
Krug E, et al, Global burden of injuries, Am J Public Health. 2000;90:523-6
Page 3
Global Burden of Trauma
• 5 million deaths/year related to trauma
– 9% of world’s deaths
– 12% of world’s burden of disease
• Measured in DALYs (Disability Adjusted Life
Years)
• Road traffic accidents (RTAs) largest component
Disease Control Priorities Project, Injuries & Violence Fact Sheet, April 2006,
http://www.dcp2.org/file/7/DCPP-Injuries_Violence.pdf
Page 4
Injury Leaders: Death & Disability
• Top causes of death
– 1.
RTAs
– 2.
Self-Inflicted injury
– 3.
Interpersonal violence
– 4.
War
• Top causes of lost DALYs
– 1.
RTAs
– 2.
War
– 3.
Interpersonal violence
– 4.
Self-Inflicted injury
Page 5
Leading causes of injury death, by age
High-Income Countries Low & Middle-Income
Countries (all causes)
(all causes)
Age 5-14
RTAs (#1)
Drowning (#3)
Homicide (#4)
Suicide (#5)
RTAs (#2)
Drowning (#3)
Age 15-29 RTAs (#1)
Suicide (#2)
Homicide (#3)
RTAs (#2)
Suicide (#4)
Homicide (#5) & War (#6)
Age 30-44 Suicide (#1)
RTAs (#2)
RTAs (#3)
Suicide (#5)
Homicide (#6)
Page 6
Trauma Burden: high risk groups
• Children & young adults
– Highest risk of death & disability (all injury causes)
• Men (vs. women)
– Homicide: 3:1 risk (6:1 at age 15-29)
• Not including war deaths
– RTAs: 5:2 risk of death
• Low- & middle income countries (vs. high-income)
– 2:1 risk of violence-related death
– 1:1 risk of unintentional injury death
• (but 90% of burden based on population)
For a thorough and readable overview of both Unintentional Injuries and Interpersonal
Violence, see Chapters 39 (Norton et al), and 40 (Rosenberg et al) in Disease Control
Priorities in Developing Countries, Jamison Ed, World Bank & Oxford University Press, 2006,
also available online at http://www.dcp2.org/pubs/DCP
Disease Control Priorities in Developing Countries
Page 7
Trauma Death Trends and Projections
Source: Mathers & Loncar, 2006
Page 8
Unintentional Injuries
• Includes
– Burns
– Drowning
– Falls
– Poisoning
– Traffic Accidents
• Focus on Road Traffic Accidents (RTAs), rationale:
– Largest component of unintentional injuries in low- and
high-income countries alike
Page 9
Distribution of
Unintentional Injuries
Low- & Middle Income
Countries, 2001
• Burden of disease is
measured in DALYs (Disability
Adjusted Life Years)
• Source: Norton R, et al,
Unintentional Injuries, in
Disease Control Priorities for
Developing Countries,
Jamison Ed., World Bank &
Oxford University Press, 2006
Page 10
Focus on RTAs
•
•
Current
– 2.1% global deaths (11th place)
– 2.6% of global DALY’s lost (9th
place)
Projections for 2030
– 2.1 million deaths/year
– 8th leading cause of death
– 4th leading cause of DALYs
(disability)
– Largest increases anticipated in
low & middle income countries
due to economic & population
growth
Photo: Credit: (c) 2003 Sammy Ndwiga, Courtesy of Photoshare
Caption: A catholic priest survives an automobile accident in Kenya.
Ameratunga S, Hijar M, Norton R. Road-traffic injuries: confronting disparities to address a global-health
problem. Lancet 2006; 367: 1533–40
Page 11
Road Traffic Accidents - Inequalities
• Road traffic injury is a social equity issue
• 30-86% of trauma admissions in low- & middle-income countries
• RTA deaths mostly among “vulnerable road users”:
– pedestrians, cyclists, motorized 2 wheelers, bus & minibus
passengers
• In high income countries the majority or RTAs involve cars, although
vulnerable users remain at higher risk of dying if involved
• Even in high income countries, the poor are more often the victims
of RTAs, have less access to post crash health care and fewer
socioeconomic resources to fall back on
Amertunga, Hijar, & Norton, 2006
Page 12
Road fraffic injury mortality rates
Page 13
Road Injury Prevention and Control
The New Understanding from WHO
•
•
•
•
•
•
“Road crash injury is largely preventable and predictable; it is a human made
problem amenable to rational analysis and countermeasure
Road safety is a multi-sectoral issue & a public health issue
Common driving errors and common pedestrian behavior should not lead to
death and serious injury
The vulnerability of the human body should be the limiting design parameter for
the traffic system
Technology transfer from high income to low income countries needs to fit local
conditions
Local knowledge needs to inform the implementation of local solutions.”
World Report on Road Traffic Injury Prevention, Peden M et al Ed. WHO 2004.
http://www.who.int/violence_injury_prevention/publications/road_traffic/world_report/en/index.html
Page 14
Drowning
• In 2000, 409,272 people drowned (not including floods or tsunamis,
water transport accidents, assaults or suicide)
• 97% of these occurred in low and middle income countries (43% in
India and China)
• In low and middle income countries most cases of drowning are not
recreation related but occur during necessary activities
• Risk factors include
– Male sex, young children, occupation (e.g., fishing), areas
vulnerable to floods, unsafe transportation, alcohol, epilepsy,
socioeconomic status, access to water
WHO Drowning Fact Sheet 2003, at:
http://www.who.int/violence_injury_prevention/publications/other_injury/en/drowning_factsheet.pd
f
Page 15
Burns
• 322,000 Fire related deaths
worldwide in 2002
– 12.2% in Africa
– 57.2% in Southeast Asia
• Leading cause of death in slums of
Karachi
• More than a million moderate to
severe burns in India per year
• Second most common injury in Nepal
• Children at high risk
WHO Burns Fact Sheet, 2004, at
http://www.who.int/violence_injury_prevention/publications/other_injury/en/burns_factsheet.pdf
Photos: Matthew Roberts, MD. An additional useful reference is:
Ahuja RB, Bhattacharya S, ABC of burns: Burns in the developing world and burn disasters. BMJ 2004. 329 :447-9.
WHO Burns Fact Sheet
Page 16
Burns
•
•
•
•
•
•
A leading cause of morbidity, disability,
disfigurement and lengthy, prolonged and
painful hospital course
In many countries there is no burn
service or burn specialist
Treatment is often expectant
– i.e, wait & see
Optimal care is resource intensive:
– Multiple surgeries, blood products,
burn units, etc.
In Australia a patient with an 80% burn is
likely to survive with satisfactory function.
In Nepal no patient with >40% survive
WHO Burns Fact Sheet
Page 17
Burns – Risk Factors
•
•
•
•
•
•
•
•
•
•
Alcohol and smoking
Open fires
Floor level stoves
Bedside fires
Kerosene appliances
Loose fitting clothing
Violence against women
Child abuse
Inadequate child supervision
Epilepsy
WHO Burns Fact Sheet
Page 18
Violence
• In 2000 1.6 million people died from violence
• 90+ % deaths in low or middle income countries
• Types of violence
– Self directed (e.g, suicide, suicide attempts)
– Interpersonal (e.g, assaults, homicide)
– Collective (e.g, War, other armed conflicts)
• Factors influencing violence
– Individual
– Relationship
– Community
– Societal
191 million people lost their lives as a result of the 25 largest instances of collective violence in the 20th
century; 60% were non-combatants.
You can access the entire document at:
http://www.who.int/violence_injury_prevention/violence/world_report/en/index.html
Page 19
Violence
• “The world does not have to
accept (violence) as an
inevitable part of the human
condition” WHO 2002
• Increasingly recognized as
global public health priority
Page 20
Collective Violence
• Wars, terrorism and other violent political conflicts that
occur within or between states
• State-perpetrated violence such as genocide,
repression, disappearances, torture
• Organized violent crime such as banditry and gang
warfare
• In top 5 causes of death, ages 5-44, African Region
Page 21
Collective Violence: Associated problems
•
•
•
•
Increased injury rate = more patients (civilian & military)
Destruction of health care capacity
Impaired access to care
General loss of infra-structure
• Communications
• Road transport of supplies
• Food availability
• Water supply
• Electricity
Page 22
Example: Loss of Health Care Capacity
• In the first 5 years of the armed internal conflict in
Mozambique [1982 -1987] direct targeting of primary health
facilities by the ‘bandits’ resulted in destruction of 31% of
the entire health care system.
• An equal percentage of health care workers were killed or
displaced.
Noormahomed AR, Cliff J: The impact on health in Mozambique of
South African destabilization. Ministry of Health, Mozambique, 1987
Page 23
Example: Impaired Access to Care
• Many injuries are in rural areas
/ most care facilities in cities.
• No functioning emergency
transport services
• Transport in normal times is
difficult, worse during conflicts
• 75% of referrals never reach
their destination
Photo: Richard Fisher, MD
Page 24
Injuries in war
• Most of the injuries are now sustained by civilians
• Penetrating trauma predominates over blunt trauma
• High-velocity gunshot wounds and landmines
Page 25
Civilian Victims
• Military personnel often have separate hospitals - for their
10% of the injuries
• Civilians account for 90% of injuries in developing
countries - with few facilities
• Informal fighters, militia groups, etc. often end up in civilian
hospitals - most are cared for without questions
Page 26
Injury Distribution
• Experience from armed conflict in Rwanda
–
–
–
–
–
Extremity
Back
Abdomen
Chest
Head & Neck
62%
4%
15%
9%
10%
[10% amputation rate]
Sundin JA. War surgery in Kigali, Rwanda: The role of the International
Committee of the Red Cross. Techniques in Orthopaedics 1995. 10:250-258
Page 27
Collective Violence Case:
High-velocity gun shot wound
• A 24 year-old male patient came to the emergency room.
He had multiple gun shot wounds to his left leg including
one in his left upper thigh - all seemed to have minimal
soft tissue damage.
• Vital signs are stable. He is alert.
• What do you do?
• See the supplementary notes for a discussion of the case
Page 28
Landmines
• Landmines are a current and future man-made disaster of
an epidemic proportion - millions of mines scattered world
wide with no means of removing them.
• If you are in an region known to have landmines - ASK
before you GO - into an unknown area. Don’t take the risk.
• Improvised explosive devices (IEDs) a.k.a. “roadside
bombs,” are more common than in many conflicts
– More powerful & deadly than antipersonnel mines
– Typically use abandoned armaments
– Target vehicles: multiple casualties
Page 29
Landmines
• Since 1960, 110 million
mines have been placed
around the world - most
remain active and
dangerous.
• The cost or making & placing
a mine is <$75
• The cost of finding &
removing a mine is $300 to
$1000.
Walsh NE, Walsh SW. Rehabilitation of landmine victims - the ultimate challenge. Bulletin WHO 81:665 - 670, 2003.
Photo: Credit: (c) 2002 Sara A. Holtz, Courtesy of Photoshare
Caption: "Danger - land mines": a warning on a billboard located just a few meters off the side of a road that leads out
the capital of Guinea-Bissau.
of
For more information see the International Campaign to Ban Landmines:
ICBL is a network of more than 1200 non-governmental organizations in 60 countries, working for a global ban on landmines.
ICBL is also Co-laureate of the 1997 Nobel Peace Prize. www.icbl.org
Page 30
Landmines
• Types
• Direct pressure - explode by being stepped on
– These injure limbs, peroneal area, abdomen
– Often result in amputations of one or both legs
• Trip wire - above surface
– Total body injury - usually a 50-yard killing range
• Hand held - explode when picked up
– Injure hands, arms and face - often cause blindness
– These are often colorful to attract children
Page 31
Landmines
• Landmine and IED injuries are likely to be the worst
injuries you encounter.
– Explosion drives high-velocity foreign bodies
[shrapnel & dirt] deep into tissues
– Massive soft tissue destruction
– Treatment is debridement - saving all living
tissue - especially skin [to be used later for
wound coverage]
– Amputation frequently required
Page 32
Landmine Ban
• 1997 Ottawa Treaty to ban antipersonnel landmines
– USA did not sign
• Culmination of the efforts of The International Campaign to
Ban Landmines
– led by Nobel Peace Prize winner, Jody Williams
• Many mines still exist, but ban may prevent many future
injuries
• …a good transition point to discuss injury prevention
strategies
Page 33
Prevention is better, and cheaper, than the cure
• Can anything be done to reduce injury rates?
• Only by eliminating the “accidents will happen” and “acts of
God” mentality. What may appear to be random events are
often predictable.
• For injury to occur many compounding factors must be in
place; the removal of just one factor may make all the
difference and prevent unnecessary deaths and disabilities.
Page 34
Injury Prevention
• Public health interventions can be characterized in terms of
three levels of prevention
– Primary Prevention
Reducing the likelihood of an event that may cause
injury
– Secondary Prevention
Reducing the impact of an event that may cause injury
– Tertiary Prevention
Reducing mortality and morbidity through post event care
Zwi A, Forjuoh S, Murugusampillay S , Odero W, Watts C Injuries in developing countries: policy
response needed now. Trans R Soc Trop Med Hyg. 1996. 90,593-595
Page 35
Primary Prevention: Collective Violence: Reducing
the risk of conflicts
• Conflict prevention
– Political dialogue
– Economic development
– Equalizing access to
resources
– Limiting rapid demographic
changes
• Conflict resolution
– Supra-national organizations
(UN, EU, OAS, etc.)
– Peace enforcement and
peace keeping (UN, NATO)
For more on Geneva Conventions: http://www.icrc.org/Web/Eng/siteeng0.nsf/htmlall/genevaconventions
Photos: Douglas Wilkinson, www.primarytraumacare.org
Page 36
Secondary prevention: violence
Reducing the impact & injuries from a war
•
•
•
•
Laws of armed conflict: Geneva conventions
Avoidance of collateral damage and non-combatant casualties
Restrictions on Weapons of Mass Destruction
Limit on “unnecessary” suffering
– “It is prohibited to employ weapons, projectiles and material and
methods of warfare of a nature to cause superfluous injury or
unnecessary suffering.” (1977)*
• Land mine ban
• Body armor (for “high tech” militaries)
• Resettlement & repatriation of displaced people (UNHCR)
*1977 protocol 1 added to 1949 Geneva convention
Page 37
Primary Prevention: RTAs
Addressing The risk factors
•
•
•
•
•
•
•
•
•
•
Regulate vehicle usage
Separate pedestrians from vehicles
Separate motor/non-motor vehicles
Improve road design/maintenance
Mandate vehicle maintenance
Improve lighting
Improve sign posting
Remove road side hazards
Enforce/create traffic regulations
Control speed (e.g., speed bumps)
Photo: Douglas Wilkinson, MD
www.primarytraumacare.org
Page 38
Secondary Prevention: RTAs
Reducing the injuries from a given event
• Address over-laden vehicles
• Address unrestrained
passengers
• Require motor-cycle helmets
• Implement crash protective
design
Photo: Matthew Roberts, MD
Page 39
Tertiary Prevention
Reducing mortality & morbidity through post event care
• Same considerations for unintentional and violent trauma
• Tertiary prevention = adequate trauma management
• Any trauma care system is only as good as the weakest link
in the chain of care
– Retrieval of casualties (pre-hospital)
– Assessment and resuscitation (in-hospital)
– Surgery if indicated (in-hospital)
– Nursing care (in-hospital)
– Rehabilitation (long-term)
Page 40
Contributing Factors: Pre-Hospital
• Emergency Medical Systems
– Poor emergency
communication (no 911)
– Poor road conditions
– Few ambulances and/or
transport personnel
– Long transport times
– Few can afford transport
(fuel, maintenance & staff)
“The Ambulance”
Photo: Andrew Kestler, MD
Page 41
Notes on: Contributing Factors: Pre-Hospital
First aid training for the general population needs to targeted to those most likely to
come across casualties e.g. commercial drivers and concentrate on the
management of the most frequently seen injuries. There is little point in teaching
Basic Life Support including CPR if the expected time to hospital is measured in
hours or days.
Husum et al described a pilot scheme in Northern Iraq and Cambodia where land
mine injuries are frequent. 5000 lay people were trained in first aid, concentrating on
control of peripheral hemorrhage. Subsequently paramedics received 450 hours of
training. The mortality from land mine injuries dropped from 40% to 9%.
Husum H, Mads G, Torben W, Van Heng Y, et al, Rural Prehospital Trauma Systems
Improve Trauma Outcome in Low-Income Countries: A Prospective Study from North
Iraq and Cambodia. Mil Med. 2003 Nov;168(11):934-40.
Page 42
Contributing Factors: In-Hospital
• Limited human & institutional
capacity to manage trauma
– Many hospitals without
emergency department
– Lack of trauma education
– Lack of diagnostic and
therapeutic tools
– Lack of rapid OR access
– Unsafe blood supply
– Inappropriate equipment
donation
Page 43
Contributing Factors: Long-term Care
• Limited capacity for ongoing
treatment & rehabilitation
– amputations &
osteomyelitis common
– limited access to
prosthetics, wheelchairs,
etc.
– most environments
unfriendly to the disabled
Page 44
How the Factors Play Out
Low – middle - & high-income cities
Overall mortality for serious injuries: Kumasi 63%, Monterrey 55%,
and Seattle 35%
Mock CN, Jurkovich GJ, nii-Amon-Kotei D, Arreola-Risa C, Maier RV. Trauma mortality patterns in three nations
at different economic levels: implications for global trauma system development. J Trauma. 1998.44:804-14.
Page 45
Auto-triage & Trauma mortality
• In high-income countries,
Improved casualty retrieval
may increase the severity of
trauma seen at the hospital
and paradoxically increase
hospital mortality
• Delays in arrival at hospital
(especially in low- & middleincome countries) may result
in “Auto-Triage”, decreasing
the severity of cases seen and
therefore mortality
Kijabe Hospital is a rural hospital 50 km north of Nairobi, Kenya staffed by 3 general surgeons, 1 orthopedic
surgeon, 4 family practitioners, 1 anaesthetist, I medical officer. There are 2 operating rooms, ashort term
ICU; onward referral is to Nairobi. Otieno et al described 202 trauma patients in 6 months; the mean
distance to hospital was 60km and the mean time to hospital was 9 hours. The overall mortality was 3.5,
the mortality of those arriving < 2 hours was 9%, the mortality of those arriving > 2 < 24Hours was 1.3%
and the mortality of those arriving > 24 hours was 1.4%. One implication is that those whose arrival at
hospital is delayed may have been selected for survival. --- Otieno T, Woodfield JC, Bird P, Hill AG,
Trauma in Rural Kenya. Injury. 2004 Dec;35:1228-33.
Photo: Matthew Roberts, MD
Page 46
Trimodal Distribution of Trauma Deaths
• Basis for the “Golden Hour” concept & focus on early trauma care
50
45
40
35
30
25
20
15
10
5
0
Immediate
Early (Hours)
Late (Days-Weeks)
Trunkey described, in the 1980’s, a trimodal distribution of civilian deaths from trauma the USA. Does this
apply to the developing world? --- Trunkey DD, “Trauma,” Sci Am 1983, 249:28
Page 47
Golden Hour Realism
• 4 weeks after the 2005 Kashmir
Quake, 41 villages in Pakistan
had not yet been accessed by
the relief & rescue teams due to
destroyed roads by the quake.
• Often, trauma care in the first
hour is far from realistic.
• Consider: Silver Day? Bronze
week?
Photos and content from BBC website: http://news.bbc.co.uk/
Page 48
Tertiary Prevention: Pre-hospital Interventions
• Increasing access to mobile phones/service worldwide may offset some
communications issues
• In Ghana most RTI casualties who reach hospital are transported in
commercial vehicles
– Intervention: first aid training for commercial drivers
• Police & firefighters in urban areas often first on scene
– Intervention: first aid training for police & firefighters
Mock et al conducted a study in Ghana to improve pre-hospital trauma care by training bus &
truck drivers
No formal EMS system in Ghana
Commercial drivers often first responders
335 drivers trained in 6-hr first aid course
Survey of 70 drivers after 11 months (avg)
61% had been involved in first aid
Self-reported improvement in:
Scene management, airway opening, external bleeding control, & splinting of extremities
Mock CN, Tiska M, Adu-Ampofo M, Boakye G.Improvements in prehospital trauma care in an
African country with no formal emergency medical services. J Trauma. 2002. 53:90-7
Page 49
Trauma management & training
(in-hospital tertiary prevention)
• Advanced Trauma Life Support (ATLS) is ubiquitous in most
developed countries, so that is difficult to assess its impact.
• Institution of ATLS in the Netherlands:
– One study showed decrease in mortality within 1 hour
• This is the “Golden Hour” in which ATLS targets.
• Difficult to show effect on overall mortality because of many
other links in the chain of trauma care
Van Olden et al, “Clinical impact of ATLS”. Am J Emerg Med 2004. 22:522-5.
Page 50
A casualty being managed according to ATLS guidelines
This patient has an endotracheal tube to maintain his airway (A) and allow positive pressure
ventilation (B). The cervical spine is immobilized in a hard collar. He has chest tubes in place
and one way seals placed over chest wounds (B). There are two large bore cannulae and a
transfusion is in progress (C). A secondary survey is in progress to identify other injuries (E).
Photo: Matthew Roberts, MD
Page 51
ATLS in the Developing World
• Trauma outcome improves following the ATLS
program in a developing country.
– Ali, Trinidad and Tobago
• Mortality 33.5% post ATLS vs. 67.5% pre-ATLS
• Mortality decreased in all wards of the hospital
• Decreased major disability, increased minor
disability
• But: ATLS is costly & designed for centers without
restricted resources
Ali J, Adam R, Stedman M, Howard M, Williams JI. Advanced trauma life support
program increases emergency room application of trauma resuscitative
procedures in a developing country. Journal of Trauma 1993, 34: 898-899
Page 52
Resource Appropriate Trauma Management
• Various organization have developed trauma care courses
or manuals suited to resource-poor settings
– WHO: Best Practice Guidelines on Emergency Surgical
Care in Disaster Situations
– WHO: Guidelines for Essential Trauma Care
– Primary Trauma Care: Course and manual with focus
on training the trainers for rapid dissemination
– Locally developed/adapted curricula
Page 53
Major Incidents - Multiple Casualties & Triage
• A major incident is one that outstrips normally available
resources
• Usually involves more than just the medical services
• Infrastructure damage, physical and societal, may affect
ability to respond
• Triage, the prioritizing of patients according to severity of
injury and urgency of care, seldom required in well staffed
western hospitals
• Essential where resources are limited
• See supplementary notes for a case study!
Page 54
Tertiary Prevention: Rehabilitation
• Prevention of early death
may lead to increased
morbidity in the community
• In some societies disability is
a worse outcome than death,
both economically and
socially
Photo: Douglas Wilkinson, MD
www.primarytraumacare.org
Page 55
Rehabilitation
• Often an overlooked aspect of healthcare in developing
countries.
• It involves both:
– Rehabilitation for acute problems - fractures/amputations
– Community based rehabilitation of chronic problems
• Disability post-trauma
• Disability from cerebral palsy, strokes, & polio
One resource for Rehabilitation in low and middle income countries is David Werner”s book on
community based rehabilitation for disabled children, “Disabled Village Children”. David Werner is also the
author of the widely translated and disseminated book “Where there is no doctor”. See:
http://www.hesperian.org/mm5/merchant.mvc?Screen=PROD&Store_Code=HB&Product_Code=B040&Cat
egory_Code=ENG
Page 56
Rehabilitation Acute Problems/Amputations
• The decision to amputate an extremity is usually based on the condition
of:
– Vascular supply
– Nerve - sensation / motor function
– Skin - coverage of the stump
– Soft tissue viability - muscle
– Bone
– Presence of infection
• To amputate or not?
– What do you need as an outcome ?
– How can you achieve the desired outcome?
From Sundin J, 1995
Page 57
Rehabilitation - Amputation Considerations
• Amputees need prostheses to
be employable in developing
countries.
• In some cultures an amputation
is socially unacceptable.
• Prostheses are expensive or
not available in most places.
• They need to be replaced
continually as they wear out.
A mine accident victim has his amputated leg
freshly bandaged at an hospital in Cambodia.
Photo: Credit: (c) 2003 Marcel Reyners, Courtesy of Photoshare
Page 58
Rehabilitation – Prosthetics
• Most countries are developing programs to
manufacture artificial limbs and to train personnel.
• Agencies involved include:
• The International Committee of the Red Cross
• Handicap International
• World Vision
• Many others
• Most programs try to use locally available materials
Page 59
Rehabilitation –
Prosthetics
Photos: Richard Fisher, MD
Page 60
Summary of Key Points
• For older children & young adults, trauma is the leading
cause of death and disability worldwide
• Trauma can be either violent or unintentional
• Road traffic accidents = largest single cause
• The best way to reduce the trauma burden: prevention
• Education & other basic measures can improve trauma
care in developing countries
Page 61
General References
Papers
See supplementary notes for cited papers.
Books
Disease Control Priorities in Developing Countries, Jamison DT et al
Ed, World Bank & Oxford University Press, 2006, also available
online at http://www.dcp2.org/pubs/DCP
See supplementary notes for cited books.
Web links
See supplementary notes for suggested web links.
Page 62
Credits
Dr. Andrew Kestler, MD
Division of Emergency Medicine
U. of Colorado Denver, School of Medicine
Dr. Matthew Roberts, BM, BCh
Department of Anesthesiology
U. of Colorado Denver, School of Medicine
Dr. Richard Fisher, MD
Department of Orthopedics
U. of Colorado Denver, School of Medicine
Page 63
The Global Health Education Consortium gratefully acknowledges the
support provided for developing these teaching modules from:
Sponsors
Margaret Kendrick Blodgett Foundation
The Josiah Macy, Jr. Foundation
Arnold P. Gold Foundation
This work is licensed under a
Creative Commons Attribution-Noncommercial-No Derivative Works 3.0
United States License.