COMPARATIVE STUDY between GSW & RTA

[dr-awale]

ABSTRACT

Injuries are a public health problem in developing countries whether gunshot injuries or road traffic accident, resulting in major financial and productively losses and are associated with profound morbidity and mortality injuries vulnerable populations such as refugees and displaced people, make an even greater impact on loss of life.
Many previous studies were focused specific sites but our study was aimed to review the literature to estimate the magnitude and prevalence of gunshot wound and road traffic accident in Medina hospital, Mogadishu –Somalia.
Cross-sectional study from January to December 2007 was collected from records in according to mode of injury, body parts involved, sex distribution and fatalities. The main results were: road traffic accident account for 8.8 deaths per 339 patients and gun shot injuries were responsible for 13.1 deaths per 1371 patients proportion of persons below 25years were more in injuries and fatalities due to gunshot wound and road traffic accident. Among road traffic accident 53.3% died of head injures, and gunshot wound 36.1 died of abdominal injures.
 
Introduction:
Trauma:  is any injury, whether physically or emotionally inflicted.
"Trauma" has both a medical and a psychiatric definition. Medically, "trauma" refers to a Serious or critical bodily injury, wound, or shock.  This definition is often associated with trauma medicine practiced in emergency rooms and represents a popular view of the term. In psychiatry, "trauma" has assumed a different meaning and refers to an experience that is emotionally painful, distressful, or shocking, which often results in lasting mental and physical effects.
Injuries are a public health problem in developing countries resulting in major financial and productivity losses. There are several causes of injuries among them the most common are gun shoot wound (GSW) and road traffic accident.
Analysis of mechanism and type of injury permits more focused planning of medical cover and trauma prevention. Gunshot injuries are major problems worldwide from the medical and economic perspectives and are associated with profound morbidity and significant mortality.
Gunshot injuries (GSI) cause profound morbidity and significant mortality.
These injuries occur in both military and civilian settings. The causes of gunshot injuries in Somalia like many other African and developing world include communal clashes, military violence, armed robbery, hunting, political violence and rarely sporting and suicidal attempt.

Gunshot injuries (GSI) were first reported in West Africa following the Nigerian civil war of 1967-1970. It is the second commonest cause of death per 1000 in Transkei region of South Africa. Recently the incidence has been on the increase worldwide. A case of loss of facial identification of a survivor after firearm injury to the head has been reported. Gunshot injuries could be devastating especially when it involves vital organs and could result to instant death. The cost of treating patients that survive these injuries could be enormous especially when the injuries are to the head, chest, abdomen and the spine.
Mechanism of injury by GSW:
“Bullets are composed of a casing enclosing an explosive powder charge, which, on striking, forces the end projectile element out at speeds of up to 1500 meters/second, dependant on the ammunition and type of gun. They inflict injury in a number of ways. Firstly, the projectile crushes structures along its track, similar to other forms of penetrating injury. Temporary cavitations causes shearing and compression, sometimes tearing structures (as with solid abdominal viscera) or stretching inelastic tissue (the brain is particularly susceptible), analogous to blunt trauma. As tissues recoil and hot gases dissipate, soft tissue collapses inwards with the permanent cavity being the resultant defect. Secondly, kinetic energy transfer occurs during retardation of the bullet and this may cause damage outside the tract.

Factors influencing the efficiency of kinetic energy transfer include:
1.   The kinetic energy of a body (e), proportional to mass and velocity (mv²)                 Projectile's deformation and fragmentation.
2.   Entrance profile and path traveled through the body.
3.   Biological characteristics of the transit tissues .
Projectiles tend to be classified as low velocity (<300 m/second) or high velocity (>300 m/second). Those with higher velocity may be expected, on this basis, to dissipate more energy into surrounding tissue as they slow and cause more tissue damage but this is only a very approximate guide. This 'kinetic energy dump' theory is controversial, since high velocity injuries are frequently less extensive than would be predicted and fragmentation appears to be the most effective mechanism for wounding rather than yawing or other mechanisms for slowing high velocity rounds quickly ".
“Everyday around the world, almost 16 000 people die from all types of injuries. Injuries represent 12% of the global burden of disease, the third most important cause of overall mortality and the main cause of death among 1– 40-year-olds.
The category of injuries worldwide is dominated by those incurred in road
crashes. According to WHO data, deaths from road traffic injuries account for around 25% of all deaths from injury ”.

Road traffic injuries are a major but neglected global public health problem, requiring concerted efforts for effective and sustainable prevention. Of all the systems that people have to deal with on a daily basis, road transport is the most complex and the most dangerous.

“Worldwide, the number of people killed in road traffic crashes each year is estimated at almost 1.2 million, while the number injured could be as high as 50 million – the combined population of five of the world’s large cities. The tragedy behind these figures regularly attracts less media attention than other, less frequent but more unusual types of tragedy.
What is worse, without increased efforts and new initiatives, the total number of road traffic deaths worldwide and injuries is forecast to rise by some 65% between 2000 and 2020, and in low-income and middle-income countries deaths are expected to increase by as much as 80%. The majority of such deaths are currently among “vulnerable road users” – pedestrians, pedal cyclists and motorcyclists. In high-income countries, deaths among car occupants continue to be predominant, but the risks per capita that vulnerable road users face are high.  
This is the first major report on road injury prevention jointly issued by the World Health Organization (WHO) and the World Bank, and underscores the concern that the two bodies share about the detrimental impact of an unsafe road transport system on public health and global development. It is the contention of the report, first, that the level of road deaths and injuries is
unacceptable, and second, that it is to a large extent avoidable.
There is thus an urgent need to recognize the worsening situation in road deaths and injuries and to take appropriate action. Road traffic injury prevention and mitigation should be given the same attention and scale of resources that is currently paid to other prominent health issues if increasing human loss and injury on the roads, with their devastating human impact and
large economic cost to society, are to be averted. Road Accidents are extremely common and the injuries suffered by those involved can vary greatly from minor whiplash to fatal injuries. Below you will find more information about the most common types of road accidents:
- Motorcycle Accident Claim
- Road Accident Compensation
- Road Accidents involving Cyclists
- Road Traffic Accident involving Emergency Vehicles
- Road Traffic Accident involving Hit & Run Drivers
- Road Traffic Accident involving Pedestrians
- Road Traffic Accident involving Uninsured or Stolen Vehicles
- Whiplash Injury Claim ”.
The aim of this study is to compare the medical impact of GSW with RTA on human in Medina hospital in the center of Mogadishu.



Literature review

1-   In December 2006 gun-shot injuries in Nigeria Hospital

This was combined retrospective and prospective study of gunshot injuries in a Nigeria hospital it was concluded that gunshot injuries occur more below age of forty years , and the limps were more injured ,total number of patients was 38 and male: female ratio was 18:1, and (78.9%) of them were below the age of 40 years.

2 – 13 August 2004: injuries among Afghanistan refugee.
The study was electronic data base of   MEDLINE POPLINE.
The literature review identified patients with reported war injuries who presented to hospital.
Injuries to extremities (45%) were more frequency than injuries to the hand or Neck (36%), thorax and abdominal (14%).
A majority of the injuries were caused by explosives which included landmines (32.5%), shell fregments (33%), and fire arms (27%).
The mean incidence of mortality in these studies was 11%.
Despite such an extensive search, limited information was found pertinent to injuries in afghan refugee residing in refugee camps.

3-1 march 2002: non-fatal injuries sustained in RTA in CHON BURI                  
      THIALAND .
Information from two major sources was reviewed: the records of eight non-referral hospitals and in the 1999 injury surveillance REPORT of CHON BURI hospital.
Information was retrieved from the record of 324 patients with traffic injury
and was recorded by four trained research assistants.
The majority of the injured patients were from CHON BURI (n: 313: 96.6%).
One third of the patients were aged below 20 and 29 years.
More than twice as many men (230, 71%) than women (94, 29%) were injured.
their study investigated the characteristic of non- fetal RTA patients who received treatment at one referral –and eight non-referral public hospitals in a province with high morbidity and mortality rates.
their study results were similar to the results of other studies conducted in referral hospitals in urban and rural Thailand.
 
4-1 January –December 2004: epidemiological study of RTA
cases; a study from south India :
This study was conducted at Jawahar institute of post graduate medical and research hospital, pondicherry, south India from 1st January 31st December 1994.
This study group consists of all the RTA victims reporting to JIPMER casualty in the above one year period.
A total of 544 RTA, involves 752 victims including 26 fatalities from 24 RTA reported jipmer hospital during this period, due to certain limitations, it was decided not to include fatal accidents.
There were 603 (83%) male, and 123(17%) female victims, the average of the victims was 31.5 years, and the highest number of victims (31.3%) were between 20-29 years of age followed by 30-39 years, and the 40-49 age group.
There were 65 children (8.9%), between 12 years of age with an average age of 7.1 years.
There is clearly a need for road safety education it should be director towards road users who are frequently involved and injury in RTA (e.g. student)

 

[dr-awale]

METHODS AND MATERIALS
AREA OF STUDY:
The study was conducted at the Medina hospital, centre of Mogadishu.
We selected this hospital because it is a common for all civilians.
 
Figure1:Madina hospital
Medina hospital was police hospital in south Mogadishu, the building of the hospital was started on 1967 and finished on 1979, for the first time this hospital has been closed for security purpose after the civil war broke out in the country.
In 2000 it was reopened as a community based hospital with the support of international committee of the Red Cross (ICRC).
The hospital consists of three different parts:
1- Triage 
2- Operation theatre
3- And three wards
- Male ward
- Female wards
- And intensive care unit

 
Figure2: triage
SAMPLE SIZE:
1371 of gunshot injuries and 339 of road traffic accident were chosen from
the record book in medina hospital.
AIMS OF THE RESEARCH:
-   To complete our studies as part of our graduation from the   university.
-   To estimate the prevalence of injuries of both types in madina hospital         
            from January to December 2007
-   To raise awareness about the magnitude and impact of road traffic
           accident and gunshot wound.
-   To increase the preventive measures that reduce casualties and enhance
the safety procedures of road accident bye policy makers 
 
RESEARCH INSTRUMENT
Graduators themselves were collected the data from admission book in Medina Hospital by recording between Januarys to December 2007.

METHODS:
The three graduators were visiting in medina hospital daily for collecting data.
The study period was from January to December 2007.The study group consisted of road traffic accidents and gun shot wound victims to this hospital during the above mentioned  period.
In our study we used cross sectional method as a study design.
For the purpose of the study, a road traffic accident was defined as an accident which took place on the road between two or more objects, one of which had to be any kind of a moving vehicle to the inside and out side of the
city. Any injury on the road with out involvement of vehicle (e.g. a person slipping and falling) were excluded from the study. In the gun shot injuries was defined as injuries coursed by bullets only but shells were excluded from the study.
 
Results and discussion
Results of gun-shot / wound and road traffic accident :
Table 1:  Age Sex Distribution Of Gun-shot Wound victims
Age intervals   Sex   Percentage
(Years)       Male                     Female                                   (%)
0 -   14       50                          36   6.3
15 – 24     365                          53   30.1
25 – 34     387                          42   31.3
35 – 44    186                           30   15.8
45 – 54    106                           15   8.8
55 – 64      45                           14   4.3
> 65      29                           13   3.1
Totals   1168                                203                                                                          1371

The highest number of victims (429, 31.3%) were from 25-34 years of age followed by 418 (30.1%) in the age group of 15-24 years. More than 80% of victims (1149) were under 45 years of age.
This study was based on the analysis of 1371 patients with gun-shot wound and 339 patients with road traffic accident admitted to Medina hospital between January – December 2007 so as to compare. In Table One above which shows 1168 of (85.1%) patients were Male and 203 of (14.8%) were Female, as shown above in tablet one. At the age of the patients range from 0 to more than 65 years.
In table (1) shows: 36.4% were below the age of 25 years and 31.3% were under the age of 35 years, while 28.9% were aged between 35 – 65 years.
And the lowest percentages of 3.1% were among patients who aged more
than 65 years old.
The injuries were highest among patients who aged between 25 – 34 years.
(31.3%) for further details see table one.


Chart 1: Sex distribution of gun shot injuries
 

Male: female ratio was 5:1, as shown above in chart one


 
Chart 2: distribution of anatomical site of gun-shot wounds

 
The distribution of injuries by anatomical location of gun-shot wound is shown in chart (2). The most frequently injured sites were the extremities of which the lower limb was 440 (32%) and the upper limb was in 202 (15%) patients and the lowest injured site was pelvic 93 (7%). The other injured sites included abdomen (19%), thorax (15%) and head / Neck (12.4).

 
Table2: Age-sex distribution of road traffic accidents
Age intervals   Sex   Percentage
(Years)       Male                     Female   (%)
0 -   14       42                          22   18.9
15 - 24       67                          13   23.6
25 - 34      90                           13   30.4
35 - 44      32                             7   11.5
45 - 54      21                            4   7.7
55 - 64      13                            1   4.1
> 65        9                            5   4.1
Totals    274                           65   339

The highest number of victims (103, 30.4%) were from 25-34 years of age followed by (80,23.6%) in the age group 15-24 years. more than 80% of victims 286 were under 45 years of age.

In table2 shown above, 339 persons were injured as a result of road traffic accident, 274(81%) of them were males and 65(19%) were females.

42.5% were below the age of 25years ,30.4% were between 25 to 34 years of  old, while 23.3% were aged between 35-65 years.
The lowest age percentage 4.1% were aged patients more than 65 years old.the injuries was highest among patient who aged between 25-34 years(30.4%),for further details see table 2.
Chart 3:  Sex – Distribution of road traffic accidents 
 

Male: female ratio in road traffic accidents was 9:1

 
Chart 4: distribution of anatomical site of road traffic accidents

 
The distribution of injuries by anatomical location of road traffic accident was shown in chart (4). The most recurrently injured sites were the extremities and head /Neck 39.7 % and 36% respectively.
The lowest injured sites 5% were abdomen and pelvic and the thorax was 15%.

 
Comparison
We found that the total number of gun-shot victims were 1371 while the road traffic accident victims were 339 which means that most of  our sample population were gun-shot wounds under the reason of civil war, violence, security instability , and political conflicts.
In both above mentioned cases 80% were males (gun-shot wounds, 85.1% and road traffic accident 81%) and most of them are under 40 years because males of this age group are mostly involved in political clan and religious conflicts. Extremities were the most involved part of injuries in both gun-shot
wounds and road  traffic accidents with 642 (47%) and 135 (39.7%)
respectively, but abdomen is the second most injured part in gun-shot wound (19%) comparing to the road traffic accident were head/neck are the second (36%).
From here it is clear that the most common body part involved in death differs between gun-shot wounds and road traffic accident, in gun-shot abdomen was the most common and road traffic accident head/neck was the most.
We recorded our data from 1st of January to 31st December 2007. We found that the number of gun-shot wound victims from January to March were 356 26%) while road traffic accident of the same period were 83 (24.4%). And from April to June of gun-shot wound were 275 (20%) where as road traffic accident were 84 (24.6%).

 
Table: (3) Age distribution of fatalities


Type of fatalities   < 25 Years    25 – 30 years   30 – 35years   > 35 years
Road Traffic Accident   40%   30%   10%   20%
Gun-shot Wound   38.3%   41.6%   12.7%   7.2%
It was approved that the most of gun-shot fatalities were aged between 25 – 30 years (41.6%) and less than 25 years (38.3%) while road traffic accident was less than 25 years (40%) and 25 – 30 year was 30 % other age groups 30 – 35 years, more than 35 years for gun-shot wound were 12.7% and 7.2% respectively, where as in road traffic accidents 30 – 35 years (10%) and more than 35 years (20%) as shown in table (3) above.

 
Table: (4):  Body parts involved in fatalities

Accidents       Abdomen   Head  &Neck   Thorax   Limbs
Gun-shot Wound   36.1%   25%   16.1%   19.3%
Road traffic Accident   20%   53.3%   16.6%   9.9%


Nearly, 36.1% died of abdominal injury due to gun- shot wound and 25%, 19.3% and 16.1% were died head/neck, limps and chest respectively, comparing to 53.3% died of head/neck injury due to road traffic accident and 20%,16.6% and 9.9% were died abdomen, chest and limps respectively. For more details see intable (4) above.






Chart5: comparing the frequency of GSW and RTA by trimester

 
The last six months of that year was admitted the largest numbers of injured from both gun-shot wound and road traffic accidents in which gun-shot  were 740 (53.9%) while in road traffic accident  were 182 (50.5%), for more details see chart (5).







Table (5): Age wise distribution of Road Traffic Accident victims
Age in Yrs    Jan    Feb    Mar   Apr   May   June    Jul   Aug   Sep   Oct   Nov.   Dec.   Total   %
0-14   5   6   2   7   3   2   4   4   8   4   10   9   64   18.8
15-24   17   8   1   9   12   0   7   8   3   4   4   7   80   23.5
25-34   14   7   2   8   14   6   6   10   13   12   5   6   103   30.3
35-44   4   1   0   5   5   2   3   5   7   2   2   3   39   11.5
45-54   2   0   5   0   6   0   3   2   2   3   0   2   25   7.3
55-64   2   2   2   0   0   1   0   1   0   2   3   1   14   4.1
>65   2   0   1   1   1   1   1   0   1   4   2   1   14   4.1


Table (5): Shows the age of road traffic accident victims, Age group 25 – 34 Years shows almost one third of total gun-shot wound victims (30%) followed by 15 – 24 years age group (23.5%) if we consider age group 15 – 34 years,
It shows more than half of total gun-shot wound victims











Table (6): Age wise distribution of gun-shot wound victims
Age in Yrs    Jan    Feb    Mar   Apr   May   June    Jul   Aug   Sep   Oct   Nov.   Dec.   Total   %
0-14   7   2   8   3   6   5   8   14   4   7   13   9   86   6.3
15-24   40   26   50   26   28   31   36   39   31   34   41   27   409   29.8
25-34   30   40   56   30   18   28   42   45   32   46   32   30   429   31.3
35-44   15   13   19   25   11   10   22   17   20   22   23   19   216   15.8
45-54   7   4   14   13   8   6   6   10   14   15   11   13   121   8.8
55-64   5   2   8   6   6   1   3   8   2   5   14   8   68   5
>65   1   2   5   3   6   5   2   9   0   0   2   7   42   3

Table (6): Shows the age of gun-shot wound victims, Age group 25 – 34 years Shows almost one third of total gun-shot wound victims (31.3%) followed by 15 – 24 years age group (29.8%) if we consider age group 15 – 34 years, it shows more than half of total gun-shot wound victims
 
Conclusion and recommendation
It was concluded that gun-shot wound and road traffic accident occur more below age of 40 years and the limps were more injured. According to our study we have found that the impact of gun-shot wound was related high compared to patients admitted for road traffic accidents and the majority of these victims were capital residents we also observed that males were the most commonly affected victims in both gun-shot wound and road traffic accidents at the side of female victims because males are predominantly included in conflicts and crises.
So major health hazard leading to a high mortality rate of morbidity, disability and death, have a great socio-economic impact on the victim and family. Accidents mostly gunshot-wound continue to be a growing incurring heavy loss of valuable man-power and human resources. As a conclusion we would like to suggest some recommendations which are: The results of this study suggest the need for large studies that would assist various organizations to set and plan preventive programs.
Based on these observations, it is further recommended the need of       separate ICU for management of complex life threatening conditions in an       organized manner with provisions of intensive monitoring system and life sustaining therapies.   Available committed and appropriate well-trained     staff having  knowledge of adequate skill and care of providing life support  and advanced life support measures to the critically ill patients.