Do Not Own the Procedure, Own the Disease
20 January 2020 (online)
The Changing Scenario
Head injury is the leading cause of morbidity, mortality, and socioeconomic loss in India and other developing countries. The Indian data show that nearly 1.5 to 2 million persons are injured yearly, with nearly a million patients succumbing to the effects of traumatic brain and/or spine injury. In America, more than 1 million cases of traumatic brain injury have been reported annually. In developing nations, cases of traumatic brain and spine injury have been increasing each year. With this ever-increasing number of head-injured patients, there are a limited number of neurosurgeons. India has approximately 1,800 neurosurgeons for catering to the needs of 1.27 billion population.
The availability of neurosurgeons who are interested in trauma care is also decreasing continuously due to various reasons Some of these include a stressful environment, long hours of work, a poor compensation, medicolegal issues, a lack of gratifying results in severely head-injured patients, and a very poor network of social, economic, stepdown, and rehabilitative support; therefore, the ultimately responsibility of the extremely sick patient who is unlikely to improve significantly only lies with the neurosurgeon. The existing mismatch between the patients and the number of neurosurgeons, especially in rural areas, has led to the envisaging of the concept of nonneurosurgeons caring for head-injured patients.
The National Trauma Data Bank study found that head injury is reported in only 30% of trauma patients, of whom 95% receive nonoperative management. These data indicate that these mild-to-moderate head-injured patients may be managed or are being managed by nonneurosurgeons. The study by the Society of Neurological Surgeons Liability Insurance Task Force reported that 88% of the private neurosurgeons are taking far less trauma calls in an emergency situation than they were conducting a few years ago. In the government setup also, neurosurgeons are often not immediately available to treat head-injured patients, especially in hospitals in rural areas and at level 2 and 1 trauma centers. Even a developed country like the United States is not immune to this issue, with 42% of the hospitals reporting problems with neurosurgical on-call coverage. This has resulted in a transfer of patients to a higher center even from level 2 trauma centers, where neurosurgery facility should have been present. This leads to a delay in imparting adequate care.
This situation is further complicated by a recent increase in medicolegal issues during the management of these cases, which has further increased referral to higher centers. The management of these cases is demanding and often requires duties at odd hours, which is usually not preferred by senior surgeons. Several private hospitals in the peripheral areas of cities and major towns have on-call neurosurgeons managing trauma victims. The increasing violence against doctors in the country has, however, resulted in most neurosurgeons avoiding the acceptance of very severely injured patients due to which the primary treatment of these patients gets delayed because of their being referred to the higher centers.
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