THE STATE OF TRAUMA AND EMERGENCY MEDICAL

SERVICES

JAMAICA

Hugh M. Wong DM

Kingston Public HospitalJamaica

The Reality of my Job

Introduction• As in most developing and developed countries Traumatic

Injury is of great concern• High rates of traumatic injury has long been a feature of the

Jamaican reality• Trauma is a leading cause of death and disability in Jamaica

with significant adverse impact on the overall economy and on the psyche of the country.

• Reflected in the reputation of the nation as evidenced by the need for our current meeting

• Primary prevention as in any disease of public health significance is the key to reduction of the incidence of that condition

• However research has demonstrated that better organized and effective trauma care systems increase survival rates and reduce long term disability

Effects of Trauma

FamilyCommunity

• Societal Toll

Medical Costs • Economic

Premature Death and Disability

• Loss of Productivity

Contributory Factors

TraumaAlcohol Abuse

Intentional Injury

Hazardous environments

and workplaces

Poorly designed and maintained

roads

Overburdened Health care

Infrastructure

Lack of efficient Emergency response systems

WHO; Pre-hospital Trauma care systems 2005

The Current State of Trauma in

JamaicaLocal-Kingston Public Hospital

National-Hospital Monthly Statistical Reports

Accident & Emergency Department• A small department• Four treatment cubicles• Only one cubicle fully equipped as a Resuscitation

Bay• Two doctors assigned per shift to the see Level I & II

patients Medical and Surgical• Total doctors per shift maximally 9• Need to mobilize staff from other areas to assist in

patient care when necessary

Trauma Bay

TOTAL PATIENT VISITS A&E 2012MONTH REG &SEEN ADMITTEDJANUARY 6269 2038FEBRUARY 5609 1813MARCH 6112 1986APRIL 5723 1694MAY 6215 1984JUNE 6222 1960JULY 5842 1972AUGUST 6208 1905SEPTEMBER 6562 2103OCTOBER 6675 2180NOVEMBER 6391 1953DECEMBER 6287 2061

74110 23599

TRAUMA VISITSMONTH TOTAL VISITSJANUARY 183

FEBRUARY 152

MARCH 159

APRIL 161

MAY 244

JUNE 150

JULY 179

AUGUST 147

SEPTEMBER 161

OCTOBER 186

NOVEMBER 183

DECEMBER 253

2158

Trauma Mechanism

63%

21%

4%

5%5% 2%

MVAGSWSWFALLSBLUNTLACERATIONSBURNSSEXUAL ASSAULT

Trauma Visits

January February March April May June July August September October NovemberDecember0

20

40

60

80

100

120

140

160

180

200

130

120 121116

172

117

138

114 117

146141

177

53

3238

45

72

3341

33

4440 42

76

MalesFemales

Trauma Visits by Gender

January

Febru

ary

Marc

hApril

May

June

July

August

September

October

November

December

020406080

100120140160180200

FEMALESMALES

Incidence by Age and Gender

<12 12-15 yrs

16-20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 76-80 81-85 86-90 91-95 96-100

0

50

100

150

200

250

300

350

Males

Females

Incidence

Age

Time of Day

0-4 am 4-8 am 8-12 md 12-4 pm 4-8 pm 8-12 pm0

50

100

150

200

250

300

350

400

450

500

Incidence

Trauma Cases by Day of Week

Sunday

Monday

Tuesday

Wednesd

ay

Thursday

Friday

Satu

rday

0

50

100

150

200

250

300

350

Trauma Visits

Trauma as % of total Attendance

3%

97%

TRAUMA NONTRAUMA

TRAUMA ADMISSIONS AS % OF TOTAL ADMISSIONS

758; 3%

23599; 97%

TRAUMA ADMISSIONS TOTAL ADMISSIONS

Patients requiring immediate surgery as % of critical visits

7%

93%

Directly to OTTrauma visits

Patients Dying from Traumatic Injury in A&E

3%

97%

Died in A&ETrauma visit total

Deaths in the A&E Department

GSW MVA Stab Wound

Other0

5

10

15

20

25

30

35

40

Male

Female

Deaths Due to TraumaPrior to Accident and Emergency Department

GSW MVA Stab Wounds

Other0

100

200

300

400

500

600

Males

Females

Not Reported In MOHE data.

ICU Admissions by Intent

GSW Stab Wound

Blunt MVA Fall Burn Blast0

5

10

15

20

25

30

Intentional

Unintentional

Num

ber o

f Pati

ents

Intentional Unintentional

Total ICU Length of Stay by Intent

GSW Stab Wounds

Blunt MVA Fall Burns Blast0

50

100

150

200

250

300

350

400

450

500Intentional Unintentional

Day

s

• Kingston Public Hospital sees a low percentage of major trauma relative to other conditions• Medical and Non-traumatic conditions

pre-dominate

• SO WHY ARE WE HERE??

Nationally -HMSR Data

Hospitals By DesignationType A (Level 1) Type B (Level 2) Type C (Level 3) SpecialistKingston Public Hospital Spanish Town Hospital Princess Margaret

HospitalBellevue

Cornwall Regional Hospital

Savannah-la-MarHospital

Linstead Public Hospital Victoria Jubilee

University Hospital of the West Indies

St. Ann’s Bay Hospital Annotto Bay Hospital Bustamante Hospital

Mandeville Regional Hospital

Port Antonio Hospital National Chest Hospital

Port Maria Hospital Hope Institute

Falmouth Hospital Mona Rehabilitation

Lionel Town Hospital

Noel Holmes Hospital

Percy Junor Hospital

Black River Hospital

May Pen Hospital

Intentional Trauma

REGION Stab Wounds Gun ShotBlunt Injury

Sexual Assault

Intentional Lacerations Other

SERHA 1058 258 1780 539 501 1299

NERHA 551 71 2237 278 1171 2021

WRHA 574 257 2661 421 1393 1101

SRHA 221 97 1420 243 1497 883

2404 683 8098 1481 4562 5304

Intentional Trauma by Region

WRHA SRHA NERHA SERHA0

500

1000

1500

2000

2500

3000

Stab WoundsGunshotBluntSexual AssaultLacerationOther

Unintentional TraumaREGION MVC

ACCIDENTAL LACERATIONS

UNINTENTIONAL BURNS POISONING BITES DROWNING FALLS

SERHA 2750 4327 523 395 1427 9 5755

NERHA 2216 4068 329 280 2137 9 4556

WRHA 3388 3126 419 172 1237 9 4806

SRHA 1930 3181 289 103 1063 4 3074

10284 14702 1560 950 5864 31 18191

Unintentional Trauma by Region

WRHA SRHA NERHA SERHA0

1000

2000

3000

4000

5000

6000

7000

MVCLACERATIONSBURNSPOISONINGBITESFALLSDROWNING

Effects of Trauma

COSTPREVENTABLE DEATHS AND DISABILITYLOSS OF PRODUCTIVITYA CAUSE OF INCREASED MORBIDITY AND

MORTALITY IN NONTRAUMATIC CASES

Fatal, Serious and Slight Injuries

Ward et al. West Indian Med J 2009;58(5): 446

Cost of Interpersonal Violence

Ward et al. West Indian Med J 2009;58(5): 446

2.1Billion

Cost of Motor Vehicle Crashes• In 1996, the cost to the Health Sector was

approximately US$518 million. • This cost represented 13.27% of the revised

budgetary expenditure for secondary and tertiary care in 1996/1997.

• It also represented 7.87% of the revised budget of the Ministry of Health for 1996 /1997, which was J$5.33 billion.

National Road Safety Policy Doc. 2004

ADDRESSING THE PROBLEM

ResearchPre Hospital Emergency Medical

ServicesCASEVACEmergency Medicine Postgraduate

ProgramBLS,ACLS,ATLS TrainingMCM, MCI training

Research

• Numerous papers on trauma and trauma care systems from the UHWI

1. The Evolution of Emergency Medicine in Jamaica -EW Williams1, J Williams-Johnson1, AH McDonald1, S French1, R Hutson1, P Singh1, J Sadock2, R Butchey1,M Ellis1, C Thompson1, K Espinosa1Trauma registry at the UHWI

2. Trauma in the Developing World: The Jamaican Experience : JM Plummer, D Ferron-Boothe, N Meeks-Aitken, AH McDonald

3. Emergency department physician training in Jamaica: a national public hospital survey :Ivor W Crandon†1, Hyacinth E Harding†1, Shamir O Cawich*†2,Eric W Williams†3 and Jean Williams-Johnson†3

4. Non-fatal violence-related injuries in Kingston, Jamaica: a preventable drain on resources.

Zahoori, Gordon,Wilks,Ashley,Forrester

5. Trauma Admissions to the ICU of The University Hospital of the West Indies, Kingston, Jamaica : Mitchell, Scarlett, Amata

International Courses

• BLS and ACLS• Formally started in 1998• MOH and Heart Foundation of Jamaica continuing

training• Mandate to certify all doctors and nurses working in

high acuity areas

• ATLS• First held in May 2001• Jamaica Chapter of the American College of Surgeons

Disaster Management

•PAHO•World cup cricket 2007

• Mass Casualty Management• Incident Command Systems• Emergency Care and Treatment

Emergency Medicine

• Four year residency program in EM started at UWI 1996

• Follows similar program in Barbados in 1990• Emergency rooms in all Type A and B hospitals now

staffed by at least 1 Emergency Physician• Thirty seven graduates since 1996• Graduates working all over the Caribbean• EM training for Nurses in 1995

Emergency Medical Services• History• Organization• Current Status• Statistics

Emergency Medical Services

• Jamaica has a long history of ambulances attached to hospitals and almshouses from the 1930’s

• Hence the Jamaican public has a long established expectation of government provided medical transportation

• The GOJ since the 1980’s has endeavored to establish a Pre-Hospital Emergency Medical Service

• In 1996 a Pilot project was launched in the Western Regional Health Authority dubbed “Phase 1”

EMS Phase 1

• Joint Service partnership between the Jamaica Fire Brigade(JFB) and the Ministry of Health(MOH)

• JFB• Personnel

• MOH• Training• Equipment

• Ambulances• Disposables

• Technical and Clinical Supervision• Financing?

• 1996 EMS teams operating out of Fire Stations• Sav-La-Mar• Lucea• Montego Bay• Negril

• 2006• Linstead* * Phase 2

• 2007 • Falmouth

Statistics of EMS 2013

 

Savannah-la-Mar Negril Ironshore Lucea Linstead Falmouth Total

Motor Vehicle Accident 87 275 53 61 13 27 516

Other Trauma 106 427 38 34 2 9 616

Medical 514 639 148 254 29 77 1661

Obstetric & Gynaecology 8 29 9 6 2 1 55

Total Calls/Station 715 1370 248 355 46 114 2848

The Reality 

Sav-La-Mar Negril I-Shore Lucea Linstead Falmouth Total

Calls received 715 1370 248 355 46 114 2848

Calls responded

to 444 709 174 91 2 2 1422

Ambulance downtime

(days) 153 53 71 318 365 365 1325

Call Response

Calls Responded toCalls Not Responded to

Helicopter TransportCASEVAC

• Critically ill patients with time dependent injuries ( Severe Traumatic Brain Injury)

• Service provided by the Airwing of the Jamaica Defense Force

• At a cost to the MOH.• Usually from peripheral hospitals

to the Type A Hospitals –KPH, CRH and UHWI

• Also used for CASEVAC prior in the immediate after math of Hurricanes

What is required?

• A Trauma Care system that is• Realistic• Accessible• Affordable• Sustainable• Effective• Integrated• Accepted• Legally and Ethically grounded

• No need to recreate the wheel or should we?• Build on existing infrastructure• Decide on model that will work best for

Jamaica’s current situation• Allocate resources based on an objectively

measure of need

KEY ELEMENTS

Needed• Establish a lead national agency

• Ensure regional and local support

• Local administration

• Medical Direction

• Political Support

• Financing

Current• This agency already exists

• In the areas served by EMS, the users have bought into the system, if they can access it

• The administration of EMS is currently centralized

• There is no Clinical or Administrative Medical Director. An obvious failing

• There has been little or no political or legislative support

• No dedicated source of funding

The Jamaican Model?

• What model is best for Jamaica? • National System organized and controlled by Central

Government ( MOH)• Hospital Based• Local authority based-Fire Service/ Police• Volunteer Service• Private contractual arrangements with Central of Local

Government• Hybrid system

Organization

• Regional –based on the current Regional Health Authorities• Funded from taxes –Sin Taxes, Fuel levies, Vehicle Registration fees• EMS Legislation• Training and licensing• Appropriate units for the local conditions• Maintenance-service contracts• Private/Public partnerships• Communication and dispatch –Fundamental consideration• Quality control, audit and improvement-role of Medical Director• Governance• Creation of Trauma units at each regional hospital*

What are the Benefits

• Improved patient outcomes• Reduction in patients suffering major injury• More persons recovering with less disability, able to

work, earn and pay taxes• Creation of well trained and knowledgeable persons

offering trauma care• A system that is able to respond to mass casualty

situations appropriately and effectively• Engenders confidence in travelers to the island• Enhances the Tourism product

When in need of an ambulance any vehicle will do

Whither Trauma Centers

• Kingston Public Hospital widely quoted as a “Trauma Center”

• In many ways does not meet the criteria • No facility for formal training and research• No Health Information System for Data Collection to drive research• Inadequate depth of resources and personnel• No dedicated area for trauma care• Physical configuration of the Emergency Room not appropriate for

Trauma Care e.g. No ambulance bays• General Hospital resources used for all patients

• Staff• Operating Theatre• ICU• Emergency Room

Trauma Units

• Trauma unit established at each Regional Hospital• Dedicated trauma bay• Dedicated surgical team that can be assembled at short

notice• Specialized Trauma Surgeons• Dedicated Operating Theatres• Dedicated recovery beds• Dedicated Intensive care beds ( at least 2 beds)• Go for teams located at the 2 type A regional hospitals

( KPH and CRH)• Trauma Surgeon, Anesthetist, EMT or nurse

CONCLUSION

• As in any Developing country Trauma is a major cost and hindrance to development

• Jamaica has already established in rudimentary way a Trauma Care/Pre-hospital EMS

• Development of this system has been stymied by contesting and arguably more prioritized public health concerns

• Need at this juncture to re-focus and decide on priorities

• Or we may need to change careers as other opportunities develop

There are always other business opportunities

North St

Ora

nge

St

Charles St