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Radical approach to vehicle passenger safety and some of the most striking clinical trauma cases – from over 35-years of experience as a trauma surgeon


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Introduction

I would like to make my final contribution to medicine as a surgeon, having spent the last 35 years of my life working in very different trauma settings. I have recently been diagnosed with advanced metastatic pancreatic cancer and I probably will last for maybe another 2 weeks. I have therefore asked the Editors to allow me to include some of the interesting photos from my line of work, the patients I have been able to help or to save. Normally I would have considered submitting them as a couple of separate articles or cases, but since my time is running out and I will not live that long, this was really important to me. Hence, the possibility was granted and it’s a special way of saying goodbye to my profession, that I dedicated my whole life to. Here is my short bio:

I started off in the 1980’s as young surgeon in Nowy Targ, a highland town in southern Poland. There in Podhale, I had my first encounters with injuries, mostly accidents as well as soft tissue surgery. These were tough times in communist Poland, with not so much hope for the future. But my mentors always knew I had to move on and gave me some important hints and advice before my dreams about leaving for the West came true. It took time and patience before I was allowed to travel to Austria, then USA and Canada. Shortly thereafter I signed an attractive contract as a trauma surgeon in Black River, Jamaica (Fig.1).


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Figure 1. On Black River Hospital grounds.
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The real school of life for me begun on Jamaica. Not only English-wise, but primarily since I had to adapt to a new reality real fast – one had to be much more independent and aware of situations that could never be encountered in Poland at that time. In Black River I was able to develop my professional trauma workshop and find real good colleagues from America, who gave me some true inspiration for the future years (Fig. 2-5).

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Figure 2. Next to a used Black River Hospital ambulance.
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Figure 3. After a long day’s work, time to relax on one of Jamaican beaches, which was just a bicycle ride away.
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Figure 4. With colleagues in the operating room.
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Figure 5. Surprise photo taken during trauma surgery in Black River Hospital.
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Everything changed radically when my wife and I signed a medical contract and moved to the Republic of South Africa. We received free accommodation in a big house, good salary and additional benefits. But these were Apartheid times, so no wonder. Initially working in a long-forgotten, bush hospital for the black community in Maandagshoek (back then in Lebowa Homeland) with my wife, the anaesthetist, I came to realise that Jamaica was nothing compared to Lebowa (Fig. 6-8).

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Figure 6. Maandagshoek Casualty from the back in 2009. Source: Stephen Korsman [1].
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Figure 7. Maandagshoek swimming pool. The pool was on HC Boshoff hospital grounds. I remember my wife and kids cleaning the pool and it was in perfect working order back then, with crystal clear water. The photo was taken in 2009. Source: Stephen Korsman [1].
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Figure 8. Maandagshoek tennis court. The court was on HC Boshoff hospital grounds, nearby the swimming pool. I remember playing tennis with my wife and son back then. It wasn’t as overgrown and cracked as in this picture from 2009. The tennis court and the swimming pool were located in the vicinity of the pastor’s house, all in lush greenery. Source: Stephen Korsman [1].
[please click on the image to enlarge]


Well, to be honest, understaffing, strikes, lack of equipment and medication were only some of the major problems along the way. There were some other doctors working there too: a couple from New Zealand, a lady from the UK and a South African doctor. Rides to school were 30 km one way. The dirt road was often flooded with Maandagshoek being then completely cut off. In addition, I soon learned that a trauma surgeon was in South Africa also a GP, an OB-GYN and a pathologist/forensic specialist in one. One of the most common procedures next to trauma surgery was in fact delivering babies and also specialising in C-sections. Already then, I also realized that Africa can be a dangerous continent, not only due to wild animal injuries but also owing to cultural reasons. For some time, the local police were finding mutilated bodies of children in the bush, with testicles, genitals and eyes removed. For us, this looked like work of a serial killer, especially that the children were murdered in a similar fashion. I was asked by the police to perform autopsies and it turned out that they had been alive in most cases when the perpetrator removed these organs. Well to our surprise, the police did not consider these crimes to be the work of a serial killer, but they already knew these were acts summoned by the witchdoctors – the so called Sangomas. These traditional healers are not licensed physicians but rather something reminiscent of old tribal times. Unfortunately some of the plant origin medicine concoctions called muti had some additives in the form of genitals or eyes. It was an easy way to persuade the Sangoma’s “patient” to take lives in order to save lives, e.g. by drinking the concoction they were told by the witchdoctor they will be getting rid of the HIV infection. The only registered effect was often profuse diarrhoea or renal failure, as I often helped such “patients” in the ER.

Well, for a rather short period of time I worked in Johannesburg, which at the time was like a war zone. Gunshot wounds and machine gun injuries, dousing victims, amputations and traffic accidents, having an ethnic, political or homicidal background, were a typical night shift. It wasn’t rare for a whole minibus of people to be shot at with an AK-47.

For more peace we moved to a small cozy mining town of Phalaborwa in Transvaal, where the children could have some perfectly safe environment to attend very good schools. At the time, we started off in the nearby black township of Namakgale, where our work in the hospital was a mixture of trauma and OB-GYN procedures. Soon after, my wife and I were offered jobs in the hospital in Phalaborwa, where the duties also involved family physician activities. Phalaborwa is also a gate to the best known safari park in Southern Africa – the Kruger National Park. At that time there were refugees from the military conflict in Mozambique crossing the game park to make it to South Africa. Unfortunately some didn’t make it past the lions and others needed help of a trauma surgeon due to animal bites.

After some time, I moved on to work as a surgeon in the town of Lydenburg and soon became the Superintendent there, then a Regional Superintendent. But life without family was tough, and when Apartheid ended and I was forced to retire, I decided to move back to Phalaborwa. Unfortunately violence and homicide spread real fast in the newly democratic South Africa, so we decided to call it quits and move back to the newly democratic Poland.

Over the recent years in Poland, I continued to work as a contract surgeon in the emergency rooms in and around Cracow and some of the photos also originate from my time working again in my home country.

In this article, I would like to fit some facts and my personal opinion on the traffic accidents and related trauma, but most importantly their prevention, and in the second part about violence and non-traffic accident related trauma.


Traffic accidents

Road safety remains a major medical, societal, psychological and economic issue. Traffic related injuries are one of the main causes of fatalities all around the globe, not only for drivers but also for passengers, especially those who don’t use seatbelts. Globally speaking, low- and middle-income countries have highest road traffic fatality rates per 100 000 population [5]. The continent with the highest traffic death rate per population is Africa [2]. In 2013, WHO reported Libya to have the highest road traffic death rate per 100 000 population estimated to be 73.4 followed by Thailand with 36.2 (Fig. 9) [2]. On the other hand, the country with the sum of most traffic fatalities in the world was China with 261 367 deaths, followed by India with 207 551 and Brazil with 46 935 deaths (Fig. 10) [3]. In the United States, the CDC states that in 2014, more than 2.3 million drivers and passengers were treated in emergency departments as the result of motor vehicle traffic crashes. As many as 21 022 passenger vehicle occupants died in car crashes. Most troubling is the fact that over half of teens and adults who died in crashes in 2014 were unrestrained at the time of the crash [6].

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Figure 9. Estimated road traffic death rate (per 100 000 population), 2013. Source: WHO [2].
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Figure 10. Estimated number of road traffic deaths, 2013. Source: WHO [3].
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Driving around Europe is relatively safe nowadays. In 2011, more than 30 000 people died on the roads of the European Union. If you observe the evolution of road safety regarding fatalities – thanks to many EU improvements – it’s on a significant decrease (Fig. 11). In 1991 there were 76 600 deaths and in 2016 the number has dropped almost 3 fold to 26 100 [4]. Over the last few years, most fatalities were reported for France, Italy, Germany and Poland. In the same time period, fatalities in Poland have dropped from 7 901 to 2 938. Although the total numbers are fewer, Polish roads are twice as dangerous as German and 3× more dangerous than UK roads, considering per population statistics.

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Figure 11. Road fatalities in the EU since 2001. The adopted Road Safety Programme which aims to cut road deaths in Europe between 2011 and 2020 sets out a mix of initiatives for EU members, focussing on improving vehicle safety, the safety of infrastructure and road users' behaviour. Source: European Commission [4].
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In my personal opinion, a lot of the traffic accidents happen owing to human factors, recklessness, specific personality or character traits, often coming together with substance abuse. The infrastructure is slowly improving, the technical aspects of the vehicles are also getting better. I do think that most traffic accidents could be prevented with special preventive measures. As to the preventive measures: education, warnings and law come as the most useful. Seatbelt use is also improving, also when it comes to their use by passengers. Back in the 80’s the vehicles were mostly equipped with front seatbelts only. Little did people realize that for all vehicle occupants’ safety, it’s crucial for all passengers, not only the driver, to buckle up. Otherwise, the forces during collisions with cars or trees are so great, that unrestrained persons are launched from their seats either through the windows or within the car, injuring or killing other occupants, including children.

Below you may see a typical rear seat passenger who did not use the seatbelt and was thrown about the inside the vehicle when it rolled. The 55 year old male suffered from concussion, severe facial trauma, and vertebral C6 fracture. The photos below show the injuries during ER admission and workup (Fig. 12, 13).



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Figure 12. The unrestrained passenger, with severe facial trauma during the initial debridement and suturing. Source: own archive.
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Figure 13. The vehicle passenger was severely concussed and suffered a C6 fracture. Source: own archive.
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In my opinion, radical informative campaigns, that are currently used for smokers, could be similarly applicable to (reckless) drivers as warning roadside banners. You may see the example I prepared, based on my own photo archive (Fig. 14).

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Figure 14. Self-designed traffic awareness banner, based on cigarette smoking warning signs.
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Violence-related and non-traffic accident trauma

Violence and homicide related trauma shows in statistics all around the globe and accounts for around 10% of global injury-related deaths. According to WHO, in 2012 there were an estimated 475 000 murders. Four fifths of homicide victims were men and 65% were aged 15–49 years. Among women, partner homicides account to 38% of all murders compared to 6% of all murders among men [7]. One of the main factors in homicide rates is easy access to guns, with approximately half of all homicides committed with a firearm. As per WHO: “homicide and most forms of interpersonal violence are strongly associated with social determinants such as social norms, gender inequality, poverty and unemployment, along with other cross-cutting risk factors such as easy access to, and misuse of, alcohol and firearms” [7].

Even in highly-developed countries violent crimes are not unusual. Trends in homicide rates by WHO region in the years 2000–2012 show that altogether Americas had the highest rate of homicides reaching 19.4 per 100 000 population. Especially in the low and middle-income countries in this region, i.e. Central and South America, the general rate peaked to 28.5 per 100 000 population. The probable reason is the criminal organizations’ related violence, corruption and political instability. On the other hand, the WHO Western Pacific Region had the lowest murder rate with 2.0/100 000 population [7]. See map in Fig.15.


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Figure 15. Homicide rates globally, according to United Nations Office on Drugs and Crime [8].
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The highest mortality rates in the world due to homicide per 100 000 population may be found in:
  1. Honduras (103.9),
  2. Venezuela (57.6) and
  3. Jamaica (45.1) [7].
Out of these countries I have worked in Jamaica and also another arena of violence – namely the 2nd most violent country in Africa, just after Lesotho, i.e. South Africa, with a homicide mortality rate of 35.7 [7]. Some of the trauma I treated, see Fig. 16-20.


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Figure 16. Potential axe murderer victim, the man also suffered a severe blow to his hand, which slowed the weapon, hitting him over the head, with less force. Despite the wound the victim was lucky to get away from his assailant. Alcohol was also the substance involved.
[please click on the image to enlarge]


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Figure 17. Another similar axe injury to the head. The man’s hand and ear were injured which explains the changed trajectory of the weapon, hitting him over the head partially with the blunt edge of the axe. The persons involved were under the influence of alcohol and an argument erupted over some minor issue, like small debt or some long forgotten quarrel.
[please click on the image to enlarge]


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Figure 18. Unsuccessful homicide victim with multiple deep knife cuts to the neck. Owing to him resisting his attacker, he was able to avoid having his arteries slashed, which would have resulted in a rather quick death. Despite heavy bleeding, all wounds were inspected and stitched back together.
[please click on the image to enlarge]


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Figure 19. Amputations and injuries to the upper limb, hands and fingers. Whether the injury relates to tool shop, fireworks or motor vehicle accidents, most are in fact owing to the human factor, i.e. improper long sleeve shirts, avoiding protective clothing, carelessness, recklessness or working under the influence.
[please click on the image to enlarge]


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Figure 20. Lower limb injuries, especially open fractures, related to motor vehicle accidents.
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To compare some of these figures, in 2012 the Iraqi rate was 18.6, Russian was 13.1, and the USA only 5.4. In Poland the same homicide rate was 1.1, surprising but smaller than the peaceful New Zealand with 1.2. Countries with the lowest homicide mortality rates are: 1. Luxembourg (0.2), 2. Japan (0.4) and 3. Iceland (0.6) [7].

Very surprisingly the same rate is sky high for Greenland (sic!), at 13-25 it is often exceeding the rate for Russia, with most of homicides due to altercation and with a high percentage of women killed [9]. On the other hand, Denmark has a very low rate of homicide: 0.9 [7]. So a weird conclusion that arises is that Greenland is in the top 15 most violent countries by homicide rate, ranking it at around Dominican Republic and Haiti, and beating such countries as Mexico, India, Thailand, Philippines, Sudan etc [7]! In USA, the number of deaths due to all homicides per latest data was 15 809 per year. Firearm homicides included as many as 10 945 deaths. On the other hand, all unintentional injury deaths in the USA amounted to: 136 053, with unintentional fall deaths (31 959), motor vehicle traffic deaths (33 736) and unintentional poisoning deaths (42,032)[10-11]. See also the enclosed Fig. 19.


Conclusions

Looking down the line of my lifetime work, I am real glad to have helped so many victims of accidents and violence-related trauma. Having seen so many current global efforts in place, many regions have become safe havens for prolonging our lives. Unfortunately many places around the globe, still resemble war zones rather than habitable areas. Also, the many military conflicts impede advancement of such preventive measures.

I would like to thank all of my colleagues, fellow physicians, surgeons, nurses and medical personnel I shared many difficult and happy moments in my career. I will not mention any names since there were really so many important persons in those last 35 years. Special word of thanks must go to my loving wife, who I am especially grateful to for all her support and help, also now that I’m ill and dying.

Last but not least, I would like to thank my son, whom I’m very proud of. Not only is he a much more decorated and renowned medical doctor and academic teacher than I ever was, but also the person that was, and still is, behind the Polish Edition of the Sanford Guide to Antimicrobial Therapy – the book that I introduced to him on Jamaica in the 80’s and the same one that I found useful in any infection related to my line of work throughout these years.


References

[1] Panoramio. Stephen Korsman. Access valid on March 1, 2017: http://www.panoramio.com/ user/3055628?photo_page=1
[2] World Health Organization. Road traffic deaths. Estimated road traffic death rate per 100 000 population, 2013. Access valid on March 1, 2017: http://gamapserver.who.int/gho/interactive_charts/ road_safety/road_traffic_deaths2/atlas.html
[3] World Health Organization. Road traffic deaths. Estimated number of road traffic deaths, 2013. Access valid on March 1, 2017: http://gamapserver.who.int/gho/interactive_charts/ road_safety/road_traffic_deaths/atlas.html
[4] European Commission. Mobility and transport. Road Safety. Statistics – accidents data. Access valid on March 1, 2017: http://ec.europa.eu/transport/ road_safety/specialist/statistics_en
[5] World Health Organization. Global Health Observatory (GHO) data. Road traffic deaths. Access valid on March 1, 2017: http://www.who.int/gho/ road_safety/mortality/en/
[6] Centers for Disease Control & Prevention. Motor Vehicle Safety. Access valid on March 1, 2017: https://www.cdc.gov/motorvehiclesafety/ seatbelts/facts.html
[7] WHO. Homicide. Access valid on March 1, 2017: http://www.who.int/gho/publications/world_health_ statistics/2016/whs2016_AnnexA_Homicide.pdf?ua=1
[8] United Nations Office on Drugs and Crime. Global Study on Homicide. Access valid on March 1, 2017: https://www.unodc.org/gsh/
[9] Christensen MR, Thomsen AH, Høyer CB, Gregersen M, Banner J. Homicide in Greenland 1985-2010. Forensic Sci Med Pathol 2016;12:40-9.
[10] CDC. Assault or Homicide. Access valid on March 1, 2017: https://www.cdc.gov/nchs/fastats/homicide.htm
[11] CDC. Accidents or Unintentional Injuries. Access valid on March 1, 2017: https://www.cdc.gov/nchs/fastats/accidental-injury.htm


Conflict of interest: none declared

Authors’ affiliations:
Private Medical Practice
ul. Bliźniaków 32
32-089 Wielka Wieś
Cracow, Poland

Corresponding author:
†Dr Andrzej Kochan has sadly passed away shortly after authorizing this article, still before it was published. All questions may now be addressed to WJOMI Editorial Office. We consider his death a big loss to the medical community.

To cite this article: Kochan A. Radical approach to vehicle passenger safety and some of the most striking clinical trauma cases – from over 35-years of experience as a trauma surgeon. World J Med Images Videos Cases 2017; 3:e16-30.

Submitted for publication: 1 March 2017
Accepted for publication: 25 March 2017
Published on: 30 April 2017



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