THE STATE OF TRAUMA AND
EMERGENCY MEDICAL
SERVICES
JAMAICA
Hugh M. Wong DM
Kingston Public Hospital
Jamaica
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
Family
Community
•Societal Toll
Medical
Costs
Premature
Death and
Disability
•Economic
•Loss of
Productivity
Contributory Factors
Hazardous
environments
and workplaces
Poorly designed
and maintained
roads
Lack of efficient
Emergency
response
systems
Intentional
Injury
Alcohol Abuse
Trauma
Overburdened
Health care
Infrastructure
WHO; Pre-hospital Trauma
care systems 2005
The Current State of
Trauma in Jamaica
Local-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 2012
MONTH
REG &SEEN
ADMITTED
JANUARY
6269
2038
FEBRUARY
5609
1813
MARCH
6112
1986
APRIL
5723
1694
MAY
6215
1984
JUNE
6222
1960
JULY
5842
1972
AUGUST
6208
1905
SEPTEMBER
6562
2103
OCTOBER
6675
2180
NOVEMBER
6391
1953
DECEMBER
6287
2061
74110
23599
TRAUMA VISITS
MONTH
TOTAL VISITS
JANUARY
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
5%
2%
5%
4%
MVA
GSW
SW
FALLS
21%
BLUNT
63%
LACERATIONS
BURNS
SEXUAL ASSAULT
Trauma Visits
200
180
177
172
160
146
140
138
141
130
120
120
121
117
116
114
117
Males
100
Females
80
76
72
60
53
45
40
38
32
20
0
44
41
33
33
40
42
Trauma Visits by Gender
200
180
160
140
120
100
80
60
40
20
0
FEMALES
MALES
Incidence by Age and Gender
350
300
Males
250
Incidence
200
150
100
50
Females
0
Age
Time of Day
500
450
400
350
Incidence
300
250
200
150
100
50
0
0-4 am
4-8 am
8-12 md
12-4 pm
4-8 pm
8-12 pm
Trauma Cases by Day of Week
350
300
250
200
150
100
50
0
Trauma Visits
Trauma as % of total Attendance
97%
3%
TRAUMA
NONTRAUMA
TRAUMA ADMISSIONS AS % OF
TOTAL ADMISSIONS
TRAUMA ADMISSIONS
TOTAL ADMISSIONS
758, 3%
23599, 97%
Patients requiring immediate
surgery as % of critical visits
7%
Directly to OT
93%
Trauma visits
Patients Dying from Traumatic Injury
in A&E
3%
Died in A&E
97%
Trauma visit total
Deaths in the A&E Department
40
35
30
25
20
Male
15
Female
10
5
0
GSW
MVA
Stab
Wound
Other
Deaths Due to Trauma
Prior to Accident and Emergency Department
600
500
400
300
Males
Females
200
100
0
GSW
MVA
Stab
Wounds
Other
Not Reported In MOHE
data.
ICU Admissions by Intent
30
Intentional
Unintentional
Number of Patients
25
20
Intentional
15
Unintentional
10
5
0
GSW
Stab
Wound
Blunt
MVA
Fall
Burn
Blast
Total ICU Length of Stay by Intent
500
Intentional
Unintentional
450
400
350
Days
300
250
200
150
100
50
0
GSW
Stab
Wounds
Blunt
MVA
Fall
Burns
Blast
• 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 Designation
Type A (Level 1)
Type B (Level 2)
Type C (Level 3)
Specialist
Kingston Public Hospital
Spanish Town Hospital
Princess Margaret
Hospital
Bellevue
Cornwall Regional
Hospital
Savannah-la-Mar
Hospital
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 Shot
Blunt
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
3000
2500
Stab Wounds
2000
Gunshot
1500
Blunt
Sexual Assault
1000
Laceration
Other
500
0
WRHA
SRHA
NERHA
SERHA
Unintentional Trauma
ACCIDENTAL UNINTENTIONAL
LACERATIONS
POISONING
BURNS
REGION
MVC
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
7000
6000
MVC
5000
LACERATIONS
4000
BURNS
3000
POISONING
BITES
2000
FALLS
1000
DROWNING
0
WRHA
SRHA
NERHA
SERHA
Effects of Trauma
COST
PREVENTABLE DEATHS AND DISABILITY
LOSS OF PRODUCTIVITY
A 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
2.1Billion
Ward et al. West Indian Med J 2009;58(5): 446
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
Research
Pre Hospital Emergency Medical
Services
CASEVAC
Emergency Medicine Postgraduate
Program
BLS,ACLS,ATLS Training
MCM, 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-Johnson , AH
McDonald , S French , R Hutson , P Singh , J Sadock , R Butchey ,M Ellis , C Thompson , K
Espinosa Trauma registry at the UHWI
1
1
1
1
1
2
1
1
1
1
2. Trauma in the Developing World: The Jamaican Experience : JM Plummer, D FerronBoothe, 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 PreHospital 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*
• 2007
• Falmouth
* Phase 2
Statistics of EMS 2013
Savannah
-la-Mar
Motor
Vehicle
Accident
Negril
Ironshore
Lucea
Linstead
Falmouth
Total
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
Calls
received
Calls
responded
to
Ambulance
downtime
(days)
Sav-LaMar
Negril
I-Shore
Lucea
Linstead
Falmouth
Total
715
1370
248
355
46
114
2848
444
709
174
91
2
2
1422
153
53
71
318
365
365
1325
Call Response
Calls Responded
to
Calls Not
Responded to
Helicopter Transport
CASEVAC
• 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
Orange St
North St
Charles St