Neurotrauma Care in India: Neurosurgeon's Point of View

Head injury is a huge public health problem in India now as the incidence is increasing in exponential fashion. The main causes are heavy population, improper road, increased vehicular traffic, lax traffic regulations, drunken driving, etc. Trauma care starts from the site of injury till the patient reaches a hospital. It is good to know that there is significant reduction in the average time interval between the time of accident and the time of patient reaching a hospital. This is mainly due to availability of emergency ambulance service in almost all parts of the country.

Neurotrauma Care Pattern in India

The head trauma patients usually get treated in tertiary hospitals with neurosurgery facility. But the numbers are so high that all could not be admitted to government hospitals due to lack of adequate trauma bed, intensive care unit (ICU) bed, emergency operation theater, etc. In view of emergency, the patients are transferred to private hospitals for admission and early intervention. Here again, the cost of treatment is different in private hospitals, because there is a different pay structure for each one. So, the patient again moves from one hospital to another till he or she fits into the budgeted hospital for admission. In this process, the so-called platinum, golden, and silver hours of neurotrauma care is lost which cost significantly toward morbidity and mortality of head injury patients.

Neurosurgeon's Point of View

As per Glasgow Coma Scale (GCS), we have three tiers of head injury patients. Mild head injury patients, that is, GCS 13 to15, which constitute 60 to 70% of total head injury patients. Then, we have moderate head injury patients, that is, GCS 9 to 12, which constitute approximately 15 to 20%. Lastly, severe head injury patients, that is, GCS 3 to 8, which is only approximately 5 to 10%. But significant problem lies here for the neurosurgeon while treating.

Some patients may have hematoma or contusion or depressed fracture as per the computed tomography (CT) scan findings which may require surgical intervention. When we as treating neurosurgeon explain the findings of the patient to the first-order relatives regarding the need of surgery, cost, outcome, and complication associated with it, the only thing the relatives expect from us is that the patient is going to be 100% normal; if yes, in how many days, etc. It is really a difficult question to answer. It has two sides to the coin. If you give a very affirmative reply, do the intervention, and the patient does not improve as expected, or improves initially and then deteriorates or deteriorates following surgery because of many reasons which could not be known many times, then the situation becomes very critical. Nowadays, the relatives become so aggressive particularly for young head injury patients, it becomes very scary for a young neurosurgeon to handle it. And if the patient dies, the relatives bring in hundreds of people, the media, create a big hue and cry, destroy hospital property, assault the hospital staff, authority, and even the treating doctor.

On the other hand, if you do not give a positive reply to the relatives regarding the outcome following enactment of the treatment to the patient, be it surgery, ICU care, intracranial pressure monitoring, etc., the relatives will start searching for an appropriate neurosurgeon who can give 100% assurance, and if they get a suitable one, they will shift the patient and you will lose the patient.

At times, they do not shift the patient but take a long time in giving the consent. In such a situation, the outcome is definitely going to be affected because of the delay in ensuing treatment. It is not only the consent which delays the treatment, it may also be due to lack of blood, financial constrain, availability of operation theater, or an anesthetist. Ultimately, all these affect the outcome.

Lately it has become a routine practice for the relatives of the patient to behave in a violent fashion to the treating doctor when the patient deteriorates or dies in spite of proper treatment, be it in a government or private hospital. Now the question is how to handle this? Should we have our personal security or request the hospital authority to increase and enhance the security? Or is time for all of us to go in unison and meet the government and put forth our problems?

For the sake of protection of residents and doctors in government as well as private hospitals, there should be implementation of a strict law regarding hooliganism in any hospital related to a patient's death, by the patient's relatives. If found guilty, the assailants should undergo rigorous imprisonment and pay maximum compensation to the hospital and the concerned individual doctors.