Primary trauma care: a 20-year review

The burden of traumatic injuries globally has never been higher. The World Health Organization (WHO) estimates 5.8 million deaths per year as a direct consequence of trauma, representing 10% of global deaths, 32% more than HIV, malaria and tuberculosis combined. Road traffic accidents alone are expected to climb to be the fifth biggest global killer by 2030. ¹

Unfortunately, many trauma victims suffer their injuries in environments far removed from major trauma centres, in countries without the resources to provide many of the interventions popularised by specialist trauma courses such as Advanced Trauma Life Support (ATLS). Low-resource countries often cannot act in the ‘golden hour’ but are more dependent on the ‘silver day’ or ‘bronze week’.

However, there is an evidence base for improved outcomes and improved knowledge with systems such as ATLS ² so should they not become a global standard of care? The byline to this is the cost burden to the individual trainee of $700–800 for initial courses, with subsequent three-yearly revalidation. Any politician, policy-maker or economist would find it difficult to argue that in countries with a healthcare budget per capita of $10–50, that such training costs would provide value for money even with trauma’s predilection towards the young tax paying workforce.^1,3,4

Primary trauma care (PTC) at its conception was designed to help train healthcare professionals in low- and middle-income countries, where resources and training are scarce or absent. It teaches them to use a systematic, two-look approach of a primary and secondary survey with appropriate early interventions popularised by ATLS.^5,6

Importantly, PTC was never intended as a concept to be forced upon these countries but a framework to their needs. The key principles were that: it was appropriate to each location’s needs and resources; it was affordable for participants; it could adapt to changing local requirements; and that the course could be sustained locally without continuing external input.

The basic structure of the course is eloquently described as 2:1:2. For the very first course, external instructors deliver two days of training to the first cohort. This is then followed by a one-day instructor course for those who have just completed the first two days and passed the exam, leading into the newly trained instructors delivering the second course ideally over the fourth and fifth days. This model can then perpetuate across a large area without further external involvement.

In the last four years, the course model has been validated in a number of studies,^7–10 showing improved knowledge of trauma care but, crucially, confidence in trauma scenarios to implement it across different healthcare professionals from medical students to nurses and doctors. Late follow-up also shows this knowledge is retained on retesting ⁷ at one year. Although there are no direct mortality data, the available data on ATLS, ² would suggest objectively that there are improved outcomes while many trainees in the course can give subjective testimony to its benefits.

The initial courses in a country are often run in the capital city, ideally in an academic hospital with visiting instructors from foreign countries. After the initial three days, local instructors are encouraged to take the course to remote areas and become locally sustainable. Devolution of responsibility for training to the local doctors and educationalists make it crucial that information is efficiently taught and retained during the comprehensive training program. This training has been progressively enhanced with new transferable principles incorporated over the last 15 years. Local reviews of training and instructors are held at regular intervals in order to maintain quality.

A PTC committee is set up in each country to organise subsequent courses, consisting of locals with cross-specialist interests.

The PTC course is unique in its emphasis on empowering local clinicians and with this in turn helping their communities.

Initial courses are cost-free to countries that require and request them, as are manuals and materials which are available online and via the uploadable electronic app.

The original manual for the course was a stand-alone text which included some transferable principles of ATLS into a simple 36-page book. It was then incorporated into Surgical Care at the District Hospital,^6,11,12 a WHO surgical textbook resulting from a review of trauma in the developing world. To date, the manual is available in 12 languages and has expanded to 64 pages in its second edition in 2015.

The first course in 1996 was a trial in Suva, Fiji funded by a grant from the World Federation of Anaesthesia. Two further trips followed before it took off and started to propagate among the local doctors. It is now core curriculum for medical students and registrars in Fiji to become instructors as part of their training programme.

PTC has been active in 76 countries (Figure 1) with many successes and a great deal of progress has been made. There have also been areas where the course has not taken root as hoped. Identifying the factors that contribute to each difficulty and adapting accordingly is one of the keys to expanding PTC even further. OPEN IN VIEWER

In Africa, PTC courses started in 1996 in Uganda, Kenya, Malawi, Zimbabwe, Sierra Leone and Lesotho. More recently from 2015, the COOL Program (COSECSA [College of Surgeons in East Central and Southern Africa] Orthopedic Link) funded by the UK Department for International Development (DFID), has trained 1800 participants and 450 instructors in over ten countries in sub-Saharan Africa over three years. ⁸

The Middle East has been another success, with ongoing courses across Iraq, Dubai, Iran, Jordan, Lebanon and Gaza. These have been endorsed locally by the Iraqi Ministry of Health, the Iranian University of Medical Science, the WHO, the Jordanian Royal Medical Service and the Red Crescent.

Most recently, with WHO funding, PTC has become established in Palestine. The West Bank alone has six full-time fellows since 2014 who have trained 322 providers in six weeks with a successful aim of 3667 in the second year. A separate project in Gaza, during 2009–2016, has run 37 courses, only two with external support, putting 776 through the course. Its local sustainability has also been guaranteed by being incorporated into the syllabus organised by the Islamic University Medical School.

In South America, efforts have been supported by the World Federation of Societies of Anaesthesiologists with courses starting in 2002. Since then, PTC has become active in eight countries. In 2006, the first South American PTC conference was held in Chile with the aim of planning its expansion across the continent.

Many separate courses across Asia have also taken root. Indonesia was one of the first countries to become self-sufficient for the course, even setting their own exams and uniquely charging $80 to enable it to sustain itself and its running costs. To date, there have been 131 courses, training nearly 4000 doctors and nurses.

India and Pakistan have been two of the biggest examples of sustainable success, adopting the course into medical and military training, as well as taking ownership for their own exams and administration.^13,14

China holds the largest number of courses and trains the most providers per year. This was largely thanks to a $3 million grant over three years from the Kadoorie Foundation in 2011. With support from the Chinese Department of Health and local CPD accreditation, the programme grew rapidly with 1053 courses over the initial three years, training nearly 21,500 providers.

PTC is a charity with global reach. In its first 20 years it has grown from a single centre course in Fiji to one that spans six continents and 76 countries. Most ventures have been a great success, but despite an established framework PTC has not lasted in some countries. The challenge for the next ten years is to press and encourage the areas where it has been successful, to embed the course in a truly sustainable way and to find ways to take root in areas where it has not been as successful.