A descriptive study of trauma cases encountered in the Grand M’Bour Hospital Emergency Department in Senegal

Introduction This study analyzed the trends of trauma cases that presented to the Emergency Department (ED) in the Grand M'Bour Hospital. We examined demographics of patients, mechanisms of trauma and types of injuries that result and times from injury to arrival. Methods This was a descriptive study using prospective ED trauma cases. Patients were selected for the study if their chief complaint was related to a traumatic injury. A trauma flow sheet was developed to obtain information. Data was collected from 6/22/16-7/13/16, with 105 cases recorded. Abstracted data included date, time of arrival, time of injury, age, gender, mechanism of injury, injury sustained and disposition. Results Patients presented to the ED for 13 different trauma-related reasons. 71% of the patients encountered had a mechanism of injury related to falls or motor vehicle accidents. The majority of patients who suffered from a fall-or motor vehicle-related injury were children, with ages 0-10 representing 31% and ages 11-20 representing 14% of the total patients. While 29% of patients were seen within 1 hour of the time of their injury, 10% of the patients were not seen until days after their injury. Conclusion We report that traumatic injuries are most commonly a result of fall-related and vehicle-related accidents. Children under the age of 20 years old are a vulnerable population for traumatic injuries. We observed that many patients were unable to seek care within a day of their injury. This was concerning that proper emergency transportation was not available, leading to potential complications or improper healing of injuries. Knowing these trends, an ED can be better prepared to treat these patients.


Introduction
Injuries have become a burgeoning epidemic in developing countries, causing more than 5 million deaths each year, roughly equal to the number of deaths from HIV, malaria and tuberculosis combined [1]. Because of the well-recognized burden of infectious disease and malnutrition, the effects of trauma and injuries on premature mortality and long-term disability are often overlooked [2]. Low-and middle-income countries are home to more than 90% of injury deaths worldwide, with motor vehicle accidents heavily contributing to that number. Africa's road traffic injury mortality rate, 32.2 per 100,000, doubles that of America's rate [3]. With economic development in low-income countries, we see an increase in the number of vehicles and an associated rise in traffic-related crashes, injuries and deaths [1]. Due to the economic growth in low-and middle-income countries, motor vehicle accidents are projected to increase from 1.2 million to 1.9 million from 2002 to 2030 [4]. Emergency Medicine is a relatively new field in the Sub-Saharan region of Africa. A study on hospitals in Ghana, Kenya, Rwanda, Tanzania and Uganda showed that none of the hospitals surveyed had enough infrastructure to follow the minimum standards and practices that the World Health Organization (WHO) has deemed essential for the provision of emergency and surgical care. In fact, only 19-50% of hospitals had the capability to provide 24-hour emergency care [5]. In Ghana, the trauma mortality rate is estimated to be 80-100 per 100,000 patients each yearapproximately 50% greater than the trauma mortality rate in a developed country [6]. The problem lies beyond the resources available in African hospitals. A preponderance of evidence supports that traumatic deaths happen in the prehospital setting more frequently in developing countries in sub-Saharan Africa compared to developed countries [6]. This shines light on the potential in these countries to develop prehospital care plans, such as an Emergency Medical Services (EMS) system. The time between an injury and when the patient arrived to the Emergency Department can vary significantly. This stems from problems such as unpaved roads and inequalities between rural and urban communities for access to an emergency response system [2].
Evidence supports that providing emergency transport can save lives by stabilizing and treating the patient earlier. A study in Sierra Leone demonstrated that an investment in an emergency vehicle and an improved communication system led to a doubling of the utilization of emergency obstetric services, as well as a 50% reduction of obstetric-case fatalities [7]. EMS systems are very costly and take time to fully develop. Therefore, countries have analyzed and found ways to build on upon their current system. For example, a study in Ghana showed that commercial vehicles-taxis, buses and trucks-were the most common modes of transportation of patients to the Emergency Department. Knowing this, commercial vehicles became the building block to further development of the Ghana EMS system [6]. Taking these strides toward improving prehospital care can allow patients to seek medical care more quickly and reduce the mortality rate from trauma. A growing emphasis also focuses on injury prevention in low-to middle-income countries to decrease the burden of injury on mortality. Although traumatic injuries have a high correlation with premature mortality and disability, certain patient populations seem to be more affected.
Road traffic injuries make up the leading causes of death and disability in the 5 to 44 year age group. Gender disparities exist as well, showing that road traffic injuries are the leading cause of death in males ages 15 to 44 years old, whereas suicide is the leading cause among females [2]. Populations at greatest risk for vehicle-related injuries include elderly, children pedestrians, cyclists, and riders of two-wheeled motor vehicles [2]. A disparity of injuries also depends on where patients live geographically, with rural areas experiencing more long-term disability from extremity injuries and urban areas encountering more head and spinal cord injuries [8]. By understanding who is affected most by traumatic injuries, communities can better target them for prevention practices.
Examining injury duration prior to initiation of medical care can allow communities to delve into why certain populations or injuries may take longer to seek medical attention. This article will explore the demographics of trauma victims at an urban hospital in Senegal, the time duration from injury to arrival in the ED, the mechanisms of injury common to the region and injury types most commonly reported.

Methods
Objective: The objective of this study was to examine the trends of trauma cases that presented to the Emergency Department in the Grand M'Bour Hospital. Specifically, we examined the mechanisms of trauma and the types of injuries that resulted. In addition, we assessed the transport times from injury to arrival in the ED.  Analytic approach: All tables and charts presented in this paper were created using Microsoft Excel Spreadsheet. Table 1 was created by analyzing which mechanisms of injury were most commonly seen in the ED. Table 2    "Sprain or Strain of Joint" includes sprains or strains of ankle or other and unspecified parts. Figure 2 and Table 3 were created to analyze how long patients endured certain traumatic injuries before being able or willing to seek medical care.

Results
Over the course of three weeks, a total of 105 patients who were victims of traumatic injuries were identified. Of these patients, we were unable to determine one patient's mechanisms of injury, one patient's subsequent injury, three patients' ages, and nine patients' transport times. These omissions were a result of either the critical nature of the patient's injury and lack of time to collect the data or the patient was unable to provide the information due to incapacitation or lack of knowledge. Patients presented to the ED for 13 different trauma-related reasons (Table 1). Fall-related injuries and motor vehicle-related injuries comprise the majority of reasons patients visit the ED (71.3%). For the purpose of our results, we divided motor vehicle-related injuries into two groups: motor vehicle accidents and pedestrian vehicle accidents. The patient in motor vehicle accidents was either the driver or a passenger. Assaults were also a relatively common mechanism of injury (13.3%). The rest of the mechanisms were only seen four times or fewer. Figure 1 Table   2). The injuries, diagnosed by physical exam and radiographic evidence, were categorized using the International Classification of Diseases (ICD-10) codes. Most patients presenting to the ED came in by private vehicle, public transportation, or walking. These modes of transportation only lengthen the critical time that patients endure before they are treated. 30 patients (29%) were seen within 1 hour of the time of their injury and 62 patients (59%) were seen within four hours. Still, many other patients were not seen until days after their injury (Figure 2). Injuries from which patients waited 72 hours to arrive to the ED included ulnar and radius fractures, lumbar spine/pelvis fracture, femur fracture, tibia fracture, shoulder dislocation, patella fracture ( Table 3). Some of these injuries become life threatening and potentially irreversible as time elapses without treatment.

Discussion
The Emergency Department (ED) plays a pivotal role in both the hospital and the public health of the community. Emergency medical care has three main components: care in the community, care during transportation and care on arrival at the receiving facility [9].  [3]. Principles and concepts of EM are found to be underrepresented in or absent from their curriculum [10]. There is a push for the globalization of EM by international organizations, such as the International Federation for Emergency Medicine and African Federation for Emergency Medicine, to expand the training opportunities and support for EM residency programs [3]. In 2009, the Ghana College of Physicians and Surgeons (GCPS) accepted a proposal to create a three-year Emergency Medicine residency program [11]. Although there is growing interest in EM training, the GCPS program is limited by funding availability to increase their class size [11]. The role of emergency nursing is also evolving across Africa in areas such as Rwanda, Malawi and South Africa [11]. In South Africa specifically, there are private and public nursing schools that offer advanced diplomas or a master's degree in emergency nursing [12]. However, currently there is no professional board that exists to define the scope of practice for an emergency trained nurse, comparable to the Emergency Nursing Association in the United States of America [12]. As educational models for EM training arise and become established in low-and middle-income countries in Western and Southern Africa, surrounding countries can use them for guidance and resources to implement EM training within their own regional medical facilities.
Our results showed a variety of long-bone fractures and head injuries as the most frequent injuries sustained. This data helps to determine specific areas of medicine and injuries that physicians can focus on in Emergency Care education. By recognizing common injuries and pathologies, physicians can better prepare themselves to handle patients presenting with these complaints and become more fluent in treatment and management to decrease long-lasting adverse effects. Effective and sustained EM programs and practices can have a beneficial impact on the public heath of countries at all levels of socioeconomic development [10]. While the majority of the patients observed in this study were seen in the ED within four hours of their injury, an alarming number of patients still waited longer than four hours to arrive to the ED. This delay has potentially fatal consequences. For example, prompt surgical treatment within four hours of a subdural hematomas, an injury commonly associated with road traffic injuries and falls, had a 60-70% functional recovery rate, compared to only 10% in patients who were operated on greater than four hours from their injury [13]. Table 3 illustrates that some of the most critical injuries that presented to the ED, such as fractures to extremities or the head and neck region and joint dislocations, were untreated for longer than 24 hours. These injuries can become life threatening as the duration of time before medical treatment increases. Many factors play a role into this delay of care, mainly: a lack of or inaccessible EMS services based on geographical location, unpaved roads, a lack of regional hospitals with adequate emergency care resources, and Page number not for citation purposes 6 use of traditional healers [2,14]. In 2004, the government in Ghana created the National Ambulance Service (NAS), with Regional Medical Coordinators responsible for managing EMS in various areas of the country [11]. In 2014, Ghana's NAS reported only 8,000 patient transports annually, with 70% of those being inter-facility transfers. These statistics are similar to what we encountered in the Grand M'Bour ED, with the majority of ambulance patients arriving or leaving as result of inter-facility transfers. The Ghana NAS concludes that their low number of annual ambulance transports is a result of poor citizen knowledge of NAS, limited infrastructure and resources and long mission times [11]. When accessibility to hospitals or medications is inadequate, for either financial or geographical reasons, many people will turn to a traditional healer to cure their medical ailments. According to the WHO, a traditional healer is "a person who is recognized by the community where he or she lives as someone competent to provide health care by using plant, animal and mineral substances and other methods based on social, cultural and religion practices" [14]. Traditional healers have a place in medicine, but certain time-sensitive illnesses require prompt EM care. We can work to reduce this delay in accessing care through public education regarding how and when to seek EM care [10]. Benefits also exist to teaching community volunteers simple but important interventions such as establishing and maintaining a patent airway, controlling external bleeding and immobilizing fractures with available resources [9]. With these various factors that impact a delay of treatment for patients with emergent injuries, underdeveloped countries can approach this problem from different avenues. It is wise and may be most beneficial where resources are scarce, to first analyze an existing system and identify areas that have the most potential for growth and that will have the most impact to decrease the transport times for patients [6]. A task like this will need collaboration from various groups of people in medicine, government, and the community to effectively help decrease the mortality rate from traumatic injuries. Additionally, low-and middle-income community hospitals should implement a systematic triage system to insure their limited human and physical emergency resource capacity is being utilized for appropriate patients, which can help decrease the time a critical patient is

Competing interests
The authors declare no competing interests.        Page number not for citation purposes 10