Trauma is the leading cause of death worldwide for individuals younger than 65 years . It continues to be responsible for more loss than cancer and heart disease together . According to the US National Center for Injury Prevention and Control, unintentional injury, suicide, and homicide account for 30.5% deaths for individuals younger than 65 years, malignancy for 16.7% of deaths, and heart disease for 12.2% of deaths .
Worldwide, about 1.2 million civilians die as a result of road traffic accidents . In many countries, the number of road traffic fatalities is particularly high. Based on investigations by the WHO, the situation in India is similar to that affecting more than 60% of the world’s population. Many of these countries are fast growing economically with access to growing numbers of vehicles in the absence of proper road infrastructure, education, licensing, traffic laws, and law enforcement. Therefore, the WHO organized the decade of road safety (2011-2020) with a goal of improving and equalizing systems in the developing world.
In both India and Germany, there has been an increase in registered motor vehicles over the last decades. However, while the number of traffic accident victims steadily dropped in Germany, there has been a sustained increase in India. In India, the available trauma care services are restricted to major cities, thus resulting in an increased incidence of deaths from traffic accidents [23-25]. The lack of organized trauma care system has led to wide disparity in trauma care delivery in different parts of the country. Germany, on the other hand, has spent a number of decades developing a well-organized countrywide trauma system. Today, there is a functioning coverage of rescue systems and a dedicated trauma network. To provide a basis for comparison, we examined the systems in these two disparate countries to get some sense of the impact of the modifications.
We therefore compared India and Germany in terms of (1) the vehicular infrastructure and causes of road traffic accident-related trauma, (2) the burden of trauma, and (3) the current trauma care and prevention, and (4) based on these observations, we suggested how India and other countries can enhance trauma care and prevention.
Search Strategy and Criteria
We obtained data from the following sources in Germany: the Federal Bureau of Statistics Germany , the Federal Highway Research Institute , The German Automobile Club (Allgemeiner Deutscher Automobil-Club [ADAC]) , and the German Trauma Register . Data from India came from the Ministry of Road Transport and Highways [23-25]. We also performed a structured search on PubMed for studies published between 1984 and 2012 using the following key words: “road traffic accidents” (334), “prevention” (106), “prehospital trauma care” (95), “trauma system” (3405), “trauma registry” (290), “trauma centers” (334), and “development of vehicles” (156). One of us (HJO) screened the titles for relevance using the following criteria: (1) time of publication and (2) comparable data from India and Germany. Of the total 4720 articles, 771 were related to trauma care. Among these, 36 were available in PubMed, 15 were published websites, and one is circulating within Germany (“Whitebook on the Care of the Severely Injured” ).
Comparison of Vehicular Infrastructure, Causes of Trauma, Burden of Trauma, and Current Trauma Care and Prevention in India and Germany
Vehicular Infrastructure and the Causes of Road Traffic Accident-related Trauma in India
India is a large country with a population of more than 1 billion. Urbanization is increasing at a startling annual rate of 26% . India has just 1% of total motor vehicles in the world, but these account for 6% of the global road traffic accidents . According to some recent studies, 13% to 18% of total deaths occur due to trauma-related injuries [12, 16, 36]. Injury is the third most important cause of mortality in India and is the most common cause of death among individuals younger than 40 years . According to the 2011 road accident statistics , the total number of road accidents in India during 2011 was 497,686, which resulted in the deaths of 142,485 injury victims (one fatality per 3.5 accidents). These numbers translate into one road accident every minute and one road accident death every 4 minutes. The proportion of fatal accidents in total road accidents has consistently increased from 18.1% in 2002 to 24.4% in 2011. The severity of road accidents, measured in terms of persons killed per 100 accidents, has also increased from 20.8 in 2002 to 28.6 in 2011 .
The detailed age profile of accident victims other than the drivers reveals the group aged 25 to 65 years accounted for the largest share of the 51.9% of total road accident casualties, followed by the group aged 15 to 24 years, with a share of 30.3% (2011 data) .
Driver fault remains the single most common cause of accidents, fatalities, and injuries. In 1.8% of deaths due to motorcycle accidents, the motorcyclists were judged responsible, and in 3.1% of deaths due to pedestrian-vehicular accidents, the pedestrians were judged responsible. Approximately 385,806 accidents (77.5% of total accidents) and 102,620 fatalities occurred in road accidents (72.0%), and road accident injuries in 399,911 persons (78.2%) during 2011 were caused by the driver. Within this category, exceeding the lawful speed accounted for the highest number of injuries and fatalities . Alcohol intake was the second most common cause in this category . Nonuse of helmets, poor visibility, and failure to obey traffic rules are other common factors . Other common documented causes for accidents are defects in motor vehicles, overloading vehicles, and overcrowding of vehicles .
India has one of the largest road networks in the world; the total road length in India increased more than 11 times between 1951 and 2011 (from 399,000 km to 4,690,000 km) . However, the designs of roads and vehicles have not met international safety standards. A burst of upgrading of road infrastructure has occurred but has not kept pace with the increase in number of vehicles, leading to an increasing number of road traffic accidents. The numbers of registered motor vehicles in the country, the road network in India, and the country’s population have increased at compound annual growth rates of 9.9%, 3.4%, and 1.6%, respectively, during the decade 2001 to 2011 . The total number of registered motor vehicles increased from about 0.3 million as of March 31, 1951, to about 142 million as of March 31, 2011. The majority (72%) are motorized two-wheelers such as motorcycles and scooters .
Motorized vehicles accounted for 92.4% of the total road accidents in the year 2011. Among the vehicle categories, two-wheelers accounted for the highest share (23.7%) of total road accidents, followed by trucks, three-wheelers or small transportation cars, tractors, and other articulated vehicles (22.4%); cars, jeeps, and taxis (21.3%); buses (8.7%); auto rickshaws (6.9%); and other motor vehicles (9.4%) in 2011 . In the case of India and a few other developing countries, the penetration level of two-wheelers (number of two-wheelers per 1000 persons) is 76, which is much higher than the levels of developed countries (USA, 26; UK, 21) . These statistics also point toward the unprotected nature of two-wheelers as compared to other vehicles .
Another peculiarity of Indian road traffic is the presence of a heterogeneous mixture of vehicles both motorized and nonmotorized. According to a study by the Indian Institute of Technology in Delhi, the share of nonmotorized transport varies from 30% to 70% depending on time and location . Pedestrians and bicycle riders use the same roads and make a vulnerable group for road traffic accidents. Gururaj  reported, among all accidents involving vehicles, 25% to 35% of those killed or injured are pedestrians and 7% to 10% of those killed or injured are bicyclists. Also, people come from diverse educational and socioeconomic status and have different attitudes toward road safety and traffic rules.
Socioeconomic and Disability Burden of Trauma in India
In 2000, there was an estimated financial loss of around USD 100 billion due to road traffic accidents, amounting to 3% of the national gross domestic product (GDP), which is higher than that (2%) in developed countries . Injury-related disabilities affect an estimated 3.5 million people in India; among these, about 2 million are caused by road traffic accidents . The disability-adjusted life years lost due to traffic accidents in 2004 were 7.248 million in India .
Prehospital Care in India
Prehospital care remains a major lacuna in the trauma care system of India. It is almost nonexistent in rural and semiurban areas . People often use indigenous methods of immobilization and transport of accident victims. Most of the prehospital trauma care coordinating agencies are restricted to metropolitan cities. Both governmental and private agencies participate in prehospital care; however, there are no set protocols or guidelines regarding prehospital care. Untrained and unskilled personnel provide most of the prehospital care. Only about 4% of the ambulance workers have certified training . Many ambulances are used as transport media only. Only 56% of the ambulances have one or more paramedics. This is true despite the fact that the majority of the ambulances are equipped with supplies for intravenous infusion (74%) and blood pressure measurement (62%) .
Centralised Accident and Trauma Services (CATS) in Delhi was instituted in 1991 to improve prehospital care. CATS has deployed 35 ambulances at strategic locations all over Delhi to minimize rescue time. This system will quantitatively improve starting in 2013. Each ambulance has two trained paramedics. CATS works with the Delhi police and the fire service. The central control room of CATS receives calls at telephone numbers 1099 and 102 (toll-free number) on 12 telephone lines. The calls are also received through the police control room and from the Delhi fire service through wireless sets. The central control room and ambulance stations are linked with wireless sets for facilitating two-way communication. CATS also runs training courses such as a basic course for ambulances.
In 2005, an Emergency Management and Research Institute was installed in the state of Andhra Pradesh as a public-private partnership to provide prehospital care through a toll-free telephone number 108 . It has more than 3197 ambulances across the state.
In-hospital Care in India
The existing in-hospital trauma care system in India is still in its infancy. However, India is making major efforts to provide standard trauma care for all. While world-class facilities for trauma care exist, they are predominantly restricted to major cities. The majority of trauma services are provided by private hospitals except in New Delhi, the capital of India . Many private corporate hospitals are emerging and many are already established, offering all modern diagnostic and therapeutic medical facilities, but they are not affordable for the majority of the Indian population. National insurance covers just 0.5% of the population and almost all patients and their families have to cover their own costs .
Many government hospitals offer free treatment, but there is no quality control for the care of injured patients. District and village hospitals are usually unable to deal with patients with complex trauma or multiple injuries [17, 18], although many university hospitals serve as tertiary referral centers.
The establishment of the Jai Prakash Narayan Apex Trauma Centre in New Delhi is a step forward in providing an apex institution for quality trauma care facilities. This trauma center is under the aegis of All India Institute of Medical Sciences, which is the apex institute of medical education and medical care in India. The role of this trauma center has been envisaged as an apex research and training institute in the field of trauma care . Many other dedicated trauma centers have also been established and many more are arising. A dedicated trauma center in Vellore has reduced the trauma-associated mortality from 27% to 6% .
There is still no concept of dedicated trauma surgeons in India. Orthopaedic surgeons handle most patients with trauma. There are around 12,000 orthopaedic surgeons in India (approximately the same number as in Germany including trauma surgeons but with a population about 15 times larger), with an approximate ratio of one orthopaedic surgeon to 0.1 million population; obviously this is far too few orthopaedic surgeons to manage the trauma.
To attain an efficient trauma care system for all in India is challenging. There is no separate central government agency to integrate policy making, planning, financing, and drafting guidelines for a standardized trauma care system . Lucrative urbanization has also led to restriction of good corporate trauma care hospitals to major cities only. Legislative and statuary provisions for road safety and trauma care are being laid down but are not implemented strictly. There are no universal trauma dedicated teams. Standardized training of paramedics and ambulance personnel has just started to evolve. The public health system in India is mostly self-funded. The centers that provide free trauma care are overburdened. A uniform and efficient health insurance system is the need of the hour. A trauma communication system between various steps of trauma care has started to develop but is still rudimentary.
Trauma Prevention and Education in India
Road safety and traffic management have been recognized as important aspects in trauma prevention by the government of India. The government has constituted the National Road Safety Council to make policy decisions in matters of road safety . The laws have been laid down for using helmets, using seat belts, avoiding use of mobile telephones while driving, and following road traffic regulations. However, their lack of strict implementation is still a concern. Increasingly, regular awareness programs for the public and school children on road safety are being organized by various governmental and private agencies.
As unsafe roads are also a reason for the high accident rate in India, the government has initiated improvements in the management of roads, development of safer vehicles, and comprehensive response to vehicles. Several organizations have been established that are dedicated to develop road safety in India.
Trauma education has also gained momentum in India. Advanced Trauma Life Support® (ATLS®) courses have gained popularity: there are four approved and 20 proposed ATLS® sites in India, and in 2011, 366 providers and 18 instructors were trained . After its start in 2007, the Indo-Israel Trauma Education Initiative  subsequently has scheduled regular courses on trauma and trauma system management.
Vehicular Infrastructure and Causes of Road Traffic Accident-related Trauma in Germany
In 2011, there were 82 million registered citizens in Germany. Of the total population, 16.8 million people were 65 years and older and 10.9 million were children younger than 15 years. 8.2% (6.7 million) of the population between 18 and 24 years of age is at risk for accidents . The number of motor vehicles is growing: from 880,000 (including trucks) in 1951 to 52.9 million in 2011 . The increase in motor vehicles in the last 60 years was 100 times in Germany , whereas it was 473 times (142 million) in India .
In 2011, 2.4 million accidents were registered by the police. This represents a decrease of 2.1% when compared to 2010 . From 1970 to 2012, there was a reduction in deaths due to road traffic accidents from 21,300 to 3606 despite the population increase from 64 million (1970) to 82 million (2011, after German reunification). During this time, the death rate increased nearly 10 times in India (14,500 in 1970 to 142,485 in 2011) (Table 1).
Most accidents occur in August and September in Germany . Most accidents happen between 3 and 6 pm in both countries [24, 39] (Table 2). Due to strict laws, alcohol-related deaths have decreased in Germany . In 1975, 3641 persons were killed due to alcohol in traffic accidents, whereas in 2011, there were 400. In India, there was an increase of persons killed due to alcohol from 9307 (2009) to 10,553 (2011) . In 2011, the incidence of alcohol-related traffic injuries was almost comparable in India and Germany, whereas excessive speed-related injuries were three times higher in India (Table 3).
In 2012, there were 3606 traffic accident-related deaths, 10.1% less than in 2011 . Age at the time of accident in India and Germany is nearly the same. More than 30% of traffic victims in India and Germany are younger than 25 years [24, 39] (Table 4). In 2011, 98% of all motorcar drivers used a seat belt in Germany , whereas 79% of drivers and only 58% of the passengers did so in India . Ninety-eight percent of motorcycle drivers in Germany used helmets, whereas in India only 31.4% used them .
Socioeconomic and Disability Burden of Trauma in Germany
In Germany, the total national costs for road traffic accidents amounted to USD 40.6 billion or 1.5% of the GDP . The disability-adjusted life years lost due to traffic accidents in 2004 were 183,200 in Germany .
Prehospital Care in Germany
For prehospital care, the entire country is covered by rescue helicopters, which are located within a radius of 50 km. Thirty-five helicopter stations are organized by the German automobile club (ADAC). The stations are notified by individuals from the scene, the police, a fire brigade, or sometimes by continuous monitoring of the police radio. The first rescue helicopter was based in Munich in 1970. In 2011, helicopters flew about 47,000 missions and treated about 43,000 patients . Besides the pilot, there is a paramedic and a doctor on board, both of whom are experienced in primary treatment of severely traumatized patients. These measures include intubation, chest tube, intravenous lines, etc. The costs are covered by insurance (85%) and by donation (15%) of the members of the automobile club, which has amounted to EUR 250 million since the year 1980. Aside from the ADAC helicopters, there are also other organizations that additionally run rescue helicopter bases. The main advantages of rescue helicopters are (1) shortened overall time to patient arrival at hospital, (2) better preclinical therapy due to the presence of a highly qualified medical team, and (3) efficient, fast, and if needed, longer-distance transport to Level I trauma centers. In addition to rescue helicopters for the severe injured, there are additionally around 1000 emergency ambulances equipped with a doctor and a paramedic who drives the car and nearly 7500 rescue ambulances equipped with two paramedics for minor and less severe injuries. Federal legislation governs rescue protocols and the rescue time (time from receiving the emergency call to arrival of adequate emergency assistance to the scene). The times vary regionally throughout Germany but average 10 to 15 minutes [10, 22].
In-hospital Care in Germany
There are 110 Level I Trauma centers that provide initial care for nearly 50% of the most severely injured patients. This is possible only through the widespread rescue helicopter network. These hospitals provide all trauma-related nonoperative and operative disciplines; 1/3 also have departments of cardiac surgery. Besides these Level I or supraregional trauma centers, there are 200 regional trauma centers (Level II) that are an integral part of facilities for maximum or specialist care. They routinely provide comprehensive emergency treatment with provision of a number of specialist disciplines and likewise maintain adequate capacity for intensive care and surgery. Facilities for basic medical care of the severely injured (Level III) have an important function in the nationwide medical care of the severely injured. They are linked into a network of usually 10 to 15 neighboring hospitals. Furthermore, agreements between the trauma centers and the prehospital rescue systems regulate the admission and transfer of patients in a trauma network (TraumaNetwork DGU®) .
When comparing data from Germany  with a study in India at the University Hospital in Pune , there appear to be three major differences: (1) the time from accident to hospitalization was 2 to 3 hours in India versus 72 minutes (including on-scene treatment) in Germany; (2) prehospital care by physicians or ambulance personnel on-scene was provided in 20.7% of patients in India while in Germany nearly 100% received such care; and (3) the observed mortality in India was 33.3% (expected value based on the Trauma and Injury Severity Score [TRISS] score, 15.7%), while in Germany the observed mortality was 12.4% (expected value based on the TRISS score, 15.1%) (Table 5).
Road traffic accidents are among the leading causes of death worldwide in individuals younger than 45 years. In both India and Germany, there has been an increase in registered motor vehicles over the last decades. However, while the number of traffic accident victims steadily dropped in Germany, there has been a sustained increase in India. We therefore compared (1) the vehicular infrastructure and causes of road traffic accident-related trauma, (2) the burden of trauma, and (3) the current trauma care and prevention between India and Germany, and (4) based on these observations, we suggested how India and other countries can enhance trauma care.
Certain limitations preclude an accurate comparison of the two countries. First, the number and the quality of studies from India are limited. While we used what we believed were the best data, the data are best interpreted in a relative way, not absolutely. Nonetheless, we presume the trends are accurate. Second, the trauma systems and quality of care are not well described in India and documentation of quality control is lacking. In general, there are limited data on prehospital events regarding rescue times, transportation, and hospital stay in India. In Germany, all patients in registered hospitals must be documented in the German database and a standardized quality control exists by means of an annual report for every hospital. No such registry or database exists in India. For example, we found only one study that looked at the observed versus the expected mortality rate documented in a single trauma center at Pune. Some descriptions of the situation in India are therefore based on our experience. Therefore, it is not always possible to identify the factors that contribute to trauma outcome. Finally, there are tremendous differences in terms of geographical issues, population, and infrastructure. All these factors jeopardize any direct comparison between countries. Despite these shortcomings, we believe a number of conclusions are justified.
The sustained increase in injuries in India may be explained by the 473-fold increase in registered motor vehicles observed within the last 60 years. India is one of the fastest growing countries in the world and has one of the largest road networks. The travel patterns in India are characterized by the presence of a heterogeneous mix of vehicles of different sizes, shapes, and engine capacity. The nonmotorized transport varies from 30% to 70% during peak hours in some cities depending on the time and the location. Bicycle transport remains a major mode of travel in towns, rural areas, and even cities, explaining why 23.2% of all fatal accidents belong to the two-wheeler group. As shown by Deshmukh et al. , the rate of people injured using two-wheeled transport is more than five times higher in India than in Germany. One of the similarities between countries is the time of accidents. Most severely injured patients arrive at the hospital outside normal working hours. One may therefore wonder whether a shift of the daily working hours and the availability of all resources until at least 9 pm could improve the quality of care. High speed and alcohol abuse have been among the most important causes of traffic injuries. In Germany, the highest number of deaths (21,300) occurred in 1970. Subsequent sequential legal regulations were introduced. Strict speed limits on rural roads were controlled as of 1972 and a more strict legal alcohol level of 0.08 g/dL was installed in 1973. In 1980, wearing crash helmets for two-wheeler drivers became mandatory and 4 years later using seat belts was mandatory. In 1998, the legal alcohol level was reduced to 0.05 g/dL. The resulting decrease to 3606 road deaths may be a result of one of these measures or a combination of these measures.
Another legislative change focused on the improvement of prehospital care. Communication systems in road traffic accidents in India represent a bottleneck of care. Only 14% of the systems have a dedicated central telephone number for incident reporting whereas in Germany there is 100% availability throughout the country. Prehospital care is rare in most rural and semiurban areas in India, while the concept of a coordinating agency and a designated authority is restricted mainly to major cities. However, even in those (eg, Pune: 6 million inhabitants), 80% of severely injured persons reach the hospital without any prehospital care . It is therefore likely that simple changes may be helpful in the future. These include at minimum prompt communication, activation, and response of a rescue system of some sort. The trauma system should include the assessment, treatment, and transport of injured people to appropriate healthcare facilities. Whenever no prehospital trauma care system exists, the first and most basic tier of a system can be established by teaching interested community members basic first-aid techniques. These first responders can be taught to recognize an emergency, call for help, and provide treatment until formally trained healthcare personnel arrive to give additional care. The second tier of care can be provided at the community level by those who have been trained in the principles of basic prehospital trauma care. These providers should have extended formal training in prehospital care, scene management, rescue, stabilization, and transport of injured people . The prognosis and outcome of severely injured patients depend directly on the quality of trauma care. Rapid transport into a hospital with the needed personal and structural competence is of paramount importance. Due to the small size of Germany (357,000 km2) compared to India (3.2 million km2), a tight network of helicopter-based rescue stations can be organized in Germany. Nevertheless, Australia (7 million km2) installed the Royal Flying Doctor Service of Australia using aircraft and appears to be able to reach any patient within 2 hours. Until arrival of the aircraft, initial treatment can be managed by telemedicine support [29, 38] and first-aid responders. Last year, 40,705 transports and 88,530 telehealth missions were performed in Australia [29, 38]. Successful care for patients with trauma requires fast and competent prehospital treatment. If adequately trained, bystanders at the scene care could prevent many deaths that result from airway obstruction or external hemorrhage. Therefore, first-aid training should be mandatory when applying for a permanent driver license. Police and firefighters should also receive some of the specialized training given to paramedics and ambulance drivers.
How can India and other developing countries learn from the experience in Germany? The potential strategies to reduce mortality and morbidity are basic. These include traffic education beginning in elementary school, lights in front and back of two-wheelers, and the introduction of helmet laws. The latter have reportedly reduced the incidence of head injuries to about 20% to 40% . Finally, standardized documentation of injury data may be helpful for quality control. Additional measures are summarized in the four E’s: enforcement, engineering, education, and encouragement (Table 6). Initial tactics might center on prevention, such as the strict enforcement of mandatory helmet laws for two-wheeler drivers, the enforcement of seat belt use, and the use of child restraints. Additional measures are manifold and include the enforcement of drunk-driving laws, speed control on all arterial roads, speed bumps, traffic control on all urban roads and highways outside the urban areas, bicycle lanes, pedestrian walks, and public education to adopt safe behaviors. It appears that a change for the better can only be made when education is combined with law enforcement. A further essential tactic is to establish trauma centers and a structured network of care. Given a relationship of volume of care to outcome, especially for complex or less common clinical problems, governments should help develop regional systems of care that focus on problems in core institutions that require resources to provide optimal care [14, 31-35, 40, 43]. Level I trauma centers such as the Jai Prakash Narayan Apex Trauma Center in Delhi are rare. One of the major determining factors in the continuity of care of patients and in clinical teaching of the residents relates to resident working-hour limitations and the impending shortage of trauma surgeons. It is claimed that this is due to an undesirable lifestyle, the increasing threat of malpractice litigation, and a reduction in resident support to resident working-hour limitations .
The future of trauma care in India is both promising and challenging. However, it is not as dismal as three decades ago, yet there is a long way to go. Standardized management of the activities of multidisciplinary teams toward trauma care is needed. Organization and management of trauma services, along with legislative and statuary endorsement, will enhance trauma care for India. Efforts by government and society are gaining momentum to strengthen the trauma care services, encouraged by the example of Germany. Besides improving car safety and stricter laws, the institution of a trauma registry to understand trends and assess the impact of interventions and trauma network with different hospital levels leads to improvement of patient care and lower mortality [20, 27, 49]. The TraumaNetwork DGU® in Germany is a strong clinical, educational, and economic cooperation of hospitals with different levels of competence in one region. The major goal is to ensure competent, high-quality, multidisciplinary care for every severely injured patient, even outside of the centers [21, 30]. Through 2012, 595 hospitals in 37 networks have been certified by an independent organization.
Despite the limitations of this study, namely the lack of comparable data, we believe certain conclusions might be justified: the vehicular infrastructure, causes of trauma, burden of trauma, and current trauma care and prevention are substantially different between India and Germany. Reducing morbidity and mortality in India will include road safety issues, such as standards on highways, in cars, licensing traffic regulations, safer infrastructure, and prevention of accidents. The improvements in mortality in Germany resulting from implementation of prehospital measures and advanced trauma life support measures [3, 4, 41] with established guidelines [7, 10] and qualified specialists experienced in caring for a high volume of severely injured patients might be effective in India as well.
The authors thank Andrew Evans MD for careful review of the manuscript and language editing.
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