GUEST EDITORIAL

Trauma care - the Eastern Cape story

While I am writing this editorial, the bloodshed seen in the casualty, emergency and trauma units across the Eastern Cape province still harbours fresh in my memory.

An estimated 48 000 South Africans are killed as a result of trauma-related events annually, with a further 3.5 million seeking healthcare as a result of trauma.^[12] South Africa (SA)'s injury death rate is nearly twice the global average.^[3] Rising levels of poverty and unemployment, limited access to education, abuse of alcohol and drugs, widespread access to firearms and other weapons, exposure to violence in childhood and a weak culture of enforcement are just a few of the multiple factors contributing to this carnage. The government has implemented programmes and campaigns to address these issues. These efforts may have contributed to a decrease in the percentage of non-natural deaths from 18% in 1997 to 10% in 2013, but even the latter percentage is too high.^[2] Diabetes, hypertension and HIV are all preventable, and so is violence.

Having campaigns and strategies in place to curb violence and address the underlying contributing factors is vital. Both transport accident- and assault-related deaths as a percentage of total non-natural deaths in the Eastern Cape are worryingly higher than the national average, i.e. 11.6% v. 11% and 15.7% v. 10.2%, respectively. The values are in keeping with the higher levels of poverty in the province.^[2] However, the ability to provide quality care to the victims of these injuries is similarly important.

The management of a trauma patient involves a sufficient number of highly qualified and trained individuals. Contrary to popular belief, the most critical time of intervention is at the roadside or place of injury, where the emergency medical services (EMS) need to come to the fore. A letter published in the SAMJ in 2010^[4] highlighted the deficiencies of the Eastern Cape EMS. The Metro Eastern Cape EMS responded to only 3.3% of calls within an hour. Without early resuscitation and stabilisation, the sustained efforts at a later stage in a hospital setting may prove costly and even fruitless. The situation has somewhat improved, with the provincial department purchasing 150 emergency service vehicles in 2014, with the objective of attending to patients within 40 minutes.^[5]

Despite being the second largest and third most populous province, the Eastern Cape does not have a specialist trauma surgeon. This is not due to a lack of available posts or funding, but rather to an inadequate number of prospective applicants. The trauma patients at the three tertiary-level public health facilities, i.e. the Mthatha, Port Elizabeth and East London Hospital complexes, are managed by a team of general surgeons. The situation is not much rosier in the private sector, where, to our knowledge, there is no specialist trauma surgeon.

Outside of the three complexes, the patients are managed at the peripheral hospitals - mainly by community service and junior medical officers and a few senior colleagues. Consequently, most, if not all, of the after-hours potential theatre cases are referred to one of the three complexes for surgical intervention, creating huge backlogs and waiting times.

To improve the quality of care delivered to patients in the province, a few junior medical officers and consultants working in the surgical disciplines at the East London Hospital Complex produced a book, Surgery Survival Guide. What started as a 50-page document in 2013, has grown to a 200-page surgical handbook in 2015, focusing purely on the management of common surgical emergencies, including trauma, general surgery, neurosurgery, urology, paediatric surgery, orthopaedics and intensive care. With the aid of funding from the provincial department of health, the book is now widely circulated across all health facilitates in the province. The text is very much a work in progress and it needs to be seen whether it will stand the test of time ... but Rome was not built in a day.

The Guide is just one of the initiatives and changes that needs to take place to improve trauma care in the province. Emphasis needs to be placed on every level of care - encouraging personnel to work in the discipline, improving their skill sets from prehospital care to definitive care, rehabilitation and discharge.

Not only the Eastern Cape, but the entire country is gripped by an epidemic of deliberate and non-deliberate traumatic events. These events are propagated by a background of alcohol, violence and substance abuse. The huge burden of disease, together with poor prehospital care, limited expertise and in-house training, contributes to the gross inequities that exist in our current trauma care system.

The Eastern Cape has much room for improvement and the potential to be one of the leading trauma and emergency care providers in SA. The burdens we face create unique opportunities for healthcare professionals and personnel to strive to create a healthcare system that our patients deserve.

J John
Guest editor. Department of Urology, Frere Hospital, East London Hospital Complex, East London, South Africa. jeffveenajohn@gmail.com

W Matshoba
Guest editor. Head, Department of Surgery, Frere Hospital, East London Hospital Complex, East London, South Africa

References

1. Pillay K, Ross A, Van der Linde S. Trauma unit workload at King Edward VIII Hospital, Durban, KwaZulu-Natal. S Afr Med J 2012;102:307-308.         [ Links ]

2. Mortality and Causes of Death in South Africa: Findings from Death Notification, 2013. Statistics South Africa. http://www.statssa.gov.za/publications/P03093/CoD_2013_presentation.pdf (accessed 8 May 2015).         [ Links ]

3. Matzopoulos R, Norman R, Bradshaw D. The burden of injury in South Africa: Fatal injury trends and international comparisons. In: Suffle S, Van Niekerk A, Duncan N, eds. Crime Violence and Injury Prevention in South Africa: Developments and Challenges. Tygerberg: MRC-UNISA Crime, Violence and Injury Lead Programme, 2004:9-21.         [ Links ]

4. Meents E, Boyles T. Emergency medical services - poor response time in the Eastern Cape. S Afr Med J 2010;100:790.         [ Links ]

5. E Cape gets new ambulances. SABC News, 28 July 2014. http://www.sabc.co.za/news/a/87852a8044e576c3ade1bda5ad025b24/E-Cape-gets-new-ambulances (accessed 8 May 2015).         [ Links ]