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Trauma Mortality Patterns in Three Nations at Different Economic Levels: Implications for Global Trauma System Development

Mock, Charles N. MD, PhD, FACS; Jurkovich, Gregory J. MD, FACS; nii-Amon-Kotei, David Dr Med, FWACS; Arreola-Risa, Carlos MD; Maier, Ronald V. MD, FACS

Journal of Trauma and Acute Care Surgery: May 1998 - Volume 44 - Issue 5 - p 804-814
Article: Presented At The 57Th Annual Meeting Of The American Association For The Surgery Of Trauma And The Japanese Association For Acute Medicine, September 24-27, 1997, Waikoloa, Hawaii

Background Whereas organized trauma care systems have decreased trauma mortality in the United States, trauma system design has not been well addressed in developing nations. We sought to determine areas in greatest need of improvement in the trauma systems of developing nations.

Methods We compared outcome of all seriously injured (Injury Severity Score >or=to 9 or dead), nontransferred, adults managed over 1 year in three cities in nations at different economic levels: (1) Kumasi, Ghana: low income, gross national product (GNP) per capita of $310, no emergency medical service (EMS); (2) Monterrey, Mexico: middle income, GNP $3,900, basic EMS; and (3) Seattle, Washington: high income, GNP $25,000, advanced EMS. Each city had one main trauma hospital, from which hospital data were obtained. Annual budgets (in US$) per bed for these hospitals were as follows: Kumasi, $4,100; Monterrey, $68,000; and Seattle, $606,000. Data on prehospital deaths were obtained from vital statistics registries in Monterrey and Seattle, and by an epidemiologic survey in Kumasi.

Results Mean age (34 years) and injury mechanisms (79% blunt) were similar in all locations. Mortality declined with increased economic level: Kumasi (63% of all seriously injured persons died), Monterrey (55%), and Seattle (35%). This decline was primarily due to decreases in prehospital deaths. In Kumasi, 51% of all seriously injured persons died in the field; in Monterrey, 40%; and in Seattle, 21%. Mean prehospital time declined progressively: Kumasi (102 +/- 126 minutes) > Monterrey (73 +/- 38 minutes) > Seattle (31 +/- 10 minutes). Percent of trauma patients dying in the emergency room was higher for Monterrey (11%) than for either Kumasi (3%) or Seattle (6%).

Conclusions The majority of deaths occur in the prehospital setting, indicating the importance of injury prevention in nations at all economic levels. Additional efforts for trauma care improvement in both low-income and middle-income developing nations should focus on prehospital and emergency room care. Improved emergency room care is especially important in middle-income nations which have already established a basic EMS.

From the Department of Surgery (C.N.M., D.n.-A.-K.), University of Science and Technology, Kumasi, Ghana, Department of Surgery (C.N.M., G.J.J., R.V.M.), University of Washington, Seattle, Washington, and Regional Trauma Center 21 and Santa Engracia Medical Center (C.A.-R.), Monterrey, N.L., Mexico.

This study was supported by an American Association for the Surgery of Trauma/Davis & Geck Research Scholarship.

Presented in part at the 57th Annual Meeting of the American Association for the Surgery of Trauma and the Japanese Association for Acute Medicine, September 24-27, 1997, Waikoloa, Hawaii.

Address for reprints: Charles Mock, MD, Department of Surgery, Box 359796, Harborview Medical Center, 325 Ninth Avenue, Seattle, WA 98104; email:

© Williams & Wilkins 1998. All Rights Reserved.