Camel-Related Head Injury in a High-Income Developing Country : Journal of Emergencies, Trauma, and Shock

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Original Article

Camel-Related Head Injury in a High-Income Developing Country

Hefny, Ashraf F.; Hefny, Mohamed A.1; Al-Ali, Mohamed A.2; Mousa, Hussam M.

Author Information
Journal of Emergencies, Trauma, and Shock 15(4):p 162-166, Oct–Dec 2022. | DOI: 10.4103/jets.jets_88_22
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Abstract

INTRODUCTION

Injury caused by large animals varies according to the regional distribution of the animals, their behavior, and their relationship to humans.[1] The United Arab Emirates (UAE) is a high-income developing country located at the eastern end of the Arabian Peninsula. Only 1% of its land is suitable for agriculture and more than 80% is a desert.[2] Camels are unique animals that can tolerate the desert’s hot climate in the UAE without much consumption of water or food. As a significant part of the UAE culture, camels are used as an important source of milk and food and can be used for transportation in the desert. Camel racing is a traditional sport in UAE that is a part of native lives culture and attracts a huge number of viewers in the UAE.[3]

About 90% of the world’s camels are dromedary camels, also known as the Arabian camel. All existing dromedary camels are domesticated. An adult Arabian (one-humped) camel stands 1.85 m (6 feet) at the shoulder and 2.15 m (7 feet) at the hump; the two-humped camel can be a foot taller. Adult camels weigh an average of 650 kg.[4] Camels are usually friendly to humans, however, occasionally they become very hostile, especially in rutting season, and can cause serious and sometimes fatal injuries.[5] Camels cause 83.3% of animal-related injuries in the UAE.[6]

Trauma patients with head injury have higher mortality compared with those with no head injury.[7] Furthermore, two-thirds of in-hospital trauma deaths are related to head injury. Head injury may require lengthy rehabilitation as a result of residual disability which places a great burden on national health medical resources.[8] Very few studies in the literature have discussed some aspects of camel-related head injuries.[9101112]

Previously, we have studied the biomechanics and severity of the head, face, and neck camel-related injuries in different sets of patients at different times.[13]

In the current study, we have specifically focused on camel-related head injury only.

We aimed to study the incidence, mechanism of injury, types, and outcome of camel-related head injury in Al Ain city, UAE to give recommendations on preventive measures.

METHODS

Ethical considerations

Ethical approval for this study was obtained from the Research Ethics Governance Committee, Al Ain Hospital, Al Ain, Abu Dhabi, UAE (AAHEC-04-18-086).

Data collection

We retrospectively collected data from all patients who were admitted to Al Ain Hospital with a camel-related head injury from January 1, 2015, to January 1, 2021. Al Ain Hospital is a university-affiliated community-based hospital having trauma and acute care facilities. It is located in Al Ain city, which has a population of 766,936 inhabitants (as of 2017).[14] During the 6 years of the study, all trauma patients in Al Ain city were managed at Al Ain Hospital.

The details of head injuries were studied using a specially designed study protocol. Data collected included demography, vital signs, Glasgow Coma Score (GCS) on admission, mechanism of injury, anatomical location and severity of the injury, associated injuries, and management. The patients were followed up during their hospital stay to record the length of hospital stay, complications, and outcome.

The severity of the injury of an anatomical region was calculated using the Abbreviated Injury Score (AIS) and the overall injury severity was determined using the Injury Severity Score (ISS).

Statistical analysis

The collected data were entered into a Microsoft Excel spreadsheet (Microsoft Corporation, Seattle, WA). A simple descriptive statistical analysis was performed. Data were presented as median (range) or number (%) as appropriate. Statistical analyses were performed using the Statistical Package for the Social Sciences (IBM SPSS version 26, Chicago, II, USA).

RESULTS

During the study period, 98 patients were admitted to Al Ain Hospital with camel-related injury. The estimated incidence of hospitalized patients with camel-related injuries in Al Ain city was 2.1/100,000 population.

Thirty-nine (39.8%) of the admitted patients with a camel-related injury sustained a head injury, all were males except one. The median (range) age of patients was 27 (4–51) years; only two patients were <18 years of age.

The estimated annually hospitalized patients with a camel-related head injury in Al Ain city was 0.85/100,000 population [Figure 1a]. Twenty-two (56.4%) injured patients were from the Indian subcontinent mostly of Pakistani nationality (12 patients).

F1-3
Figure 1:
Distribution of hospitalized head-injured patients by year (a) and month (b), Al Ain, United Arab Emirates 2015-2021 (n = 39)

Camel-related head injury was more common during August (23.1%) [Figure 1b].

Thirty-four (87.2%) patients were camel caregivers. Thirty-three patients (84.6%) were injured on farms and three (7.7%) were injured on the highway.

The most common primary mechanism of injury was fall while riding the camel in 24 (61.5%) patients, whereas being stepped on by the camel was the most common secondary mechanism of injury [Table 1].

T1-3
Table 1:
Primary and secondary mechanism of injury in patients with camel-related head injury, Al Ain, United Arab Emirates 2015-2021 (n=39)

All patients were admitted on the same day of injury, and none were wearing a helmet. Twenty-one (53.8%) patients had isolated head injury and 18 (46.2%) patients had associated other body region injuries. The chest and lower limb were the most associated injured body regions in 6 (15.4%) patients, followed by the neck in 5 (12.8%) patients.

Brain concussion was the most common head injury in 22 (56.4%) patients, followed by scalp lacerations and contusions in 19 (48.7%) patients [Table 2].

T2-3
Table 2:
Types of head injury of hospitalized camel-related head-injured patients, Al Ain, United Arab Emirates 2015-2021 (n=39)

Seven patients suffered an intracranial hemorrhage. Six (85.7%) of them had a history of fall from a camel, 5 (71.4%) patients had associated skull fracture, and 4 (57.1%) of them had a history of loss of consciousness. More than one type of intracranial hemorrhage was diagnosed in 5 (71.4%) patients. Intraparenchymal hemorrhagic contusion was the most common type of intracranial hemorrhage in 5 (71.4%) patients [Table 3].

T3-3
Table 3:
Types of intracranial hemorrhage of hospitalized camel-related head-injured patients, Al Ain, United Arab Emirates 2015-2021 (n=7)

The median (range) ISS of patients was 5 (1–29), the median (range) of AIS was 2 (1–5), and the median (range) GCS was 15 (5–15). About 34 (87.2%) patients had a mild traumatic brain injury (GCS 13–15), 3 (7.7%) patients had moderate (GCS 9–12), and 2 (5.1%) patients had a severe traumatic brain injury (GCS 3–8).[11]

GCS was significantly correlated to the severity of head injury measured by AIS of the head (P = 0.006, spearman’s correlation); however, it was not statistically significant in relation to the injury severity of patients calculated with ISS (P = 0. 620, Spearman’s correlation).

Fourteen (35.9%) patients had surgical procedures, 4 (10.3%) of them had craniectomy, whereas the rest had nonneurosurgical procedures.

Five patients (12.8%) patients were intubated and admitted to the intensive care unit (ICU) with a median (range) ICU stay of 5 days (3–12). About 17 (43.6%) patients were discharged within 48 h. The median (range) hospital stay was 3 (1–13) days. Twenty-two (56.4%) patients were followed up for a median (range) of 7.5 (1–60) days, whereas 17 (43.6%) patients were lost for follow-up.

Four (10.3%) patients had residual disability following the head injury. One patient had posttraumatic headache and dizziness. Another patient with a fractured base of the skull had a moderate conductive hearing loss on follow-up. One patient developed a salivary fistula on the left side, left facial nerve paralysis, and left vision loss. The fourth patient had postconcussive symptoms including confusion and forgetfulness, he was unable to take care of himself on discharge and later he was lost for follow-up.

One patient died during the study period after having decompressive craniectomy for acute subdural hemorrhage (overall mortality 2.6%). This patient was known to have chronic kidney disease and was presented to the emergency department with a history of fall from a camel with an initial GCS of 13/15 that dropped rapidly to 9/15 [Figure 2]. Postoperatively, his pupils were bilaterally dilated and nonreactive. The patient died on the 13th postoperative day due to severe traumatic brain injury. All other patients were self-dependent on discharge.

F2-3
Figure 2:
A 30-year-old camel caregiver male known to have chronic kidney disease presented with a history of fall from a camel with SCS 13/15. CT scan brain without iv contrast: (a) axial and (b) coronal cuts showing left parietal subdural hemorrhage measuring 9 mm in width (yellow arrow) causing a mass effect with a 4 mm midline shift to the right (arrowhead), subgaleal hematoma with gas foci noted in the right occipito-parietal region of the head (red arrow)

DISCUSSION

All patients in the current study were male except one female, most being young camel caregivers. In a previous study, 13.1% of camel-related injured patients who admitted to our institution were camel jockeys. Interestingly, in the current study, no camel jockeys were included in the injured patients as in the previous study.[15] This difference may be related to the new regulations by which the use of human jockeys in UAE has been gradually banned starting in the year 2005 by forbidding boys younger than 16 years of age or lighter than 45 kg from being jockeys. Instead, robot jockeys have been routinely used in camel races to avoid serious injuries to human jockeys which is a great step forward in the prevention of camel-related injuries.[121617] In the current study, the estimated incidence of hospitalized patients with camel-related injuries in Al Ain city was 2.1/100,000 population which is less than half of the incidence in a previous study (5.1/100,000 population) at the same institution.[6] This reduced incidence may be related to improving preventive measures by banning human camel jockeys. However, we cannot claim that unless we compared the number of injured patients during the race before and after banning.

Camels are domesticated in the Indian subcontinent. Most of the injured patients in this study were low-income young male workers originating from the Indian subcontinent who worked as camels’ caregivers in UAE. In the current study, none of the injured patients was wearing a helmet at the time of injury which may be related to the severity of head injury.[18] Most camel-related head injuries occurred at farms in 33 (84.6%) patients. Hence, it should be considered a work-related injury and the usage of helmets by camel caregivers at farms should be compulsory.

Injuries occurred more frequently in the summer which is similar to other studies on large animal-related injuries.[19] The study has shown that injuries are greatest during August which is a very hot month in UAE when average maximum temperatures reach above 45°C (113°F). With relative humidity, the appreciated air temperature is appraised at 53.2°C (127.8°F). Camels do not sweat until the environmental temperature reaches 40.5°C (105°F). At that time, the camels are probably most irritable and difficult to handle due to sweating and dehydration, leading to more injuries among camel caregivers, especially fall from the camels.[220] Other types of camel-related injuries as camel bites increased during rutting seasons.[15]

Falling off camels was the most common primary mechanism of head injury in 24 (61.5%) patients which is similar to other studies.[19] Patients falling from camels which are around 2 m can sustain serious head trauma. Following the primary mechanism of trauma, the camel might attack again causing a secondary trauma which increases the severity and complexity of the injuries.[15] Stepping of the camel on the victim with the hooves was the most common secondary mechanism in 3 (7.7%) patients.

Around half of the patients (53.8%) had isolated head injuries which are higher compared with 30% in our previous study about head trauma in UAE.[21] This can be related to negligence of wearing protective helmets while riding the camels at farms. The chest and lower limbs were the most commonly associated injured body regions similar to other studies showing that limb injuries are commonly associated with head trauma in children camel riders.[1011]

Concussion is defined as a traumatically induced transient disturbance of neurological function. It is a mild traumatic brain injury characterized by the rapid onset of a temporary drop in brain functions with spontaneous recovery in most patients within weeks.[22] Brain concussion was the most common head injury in the current study. Camel and horse racing sports have the highest rates of concussions in the world even more than in boxing. It is important to avoid the potentially fatal risks associated with recurrent concussions and prevent the second impact syndrome which may occasionally occur when the patient had a second concussion during the period of metabolic brain vulnerability.[23]

Similar to other studies, most patients had a mild traumatic brain injury and the GCS was significantly correlated to the severity of head injury measured by AIS.[11] Mild traumatic brain injury was recorded in 34 (87.2%) patients followed by moderate traumatic brain injury, which is comparable to other studies.[8] Patients with a history of traumatic brain injury are at higher risk of developing neurological disabilities either immediately or later in life. Although not clearly understood, the relation between traumatic brain injuries and neurological deficits is of clinical significance.[9]

Intracranial hemorrhage is a serious consequence of head trauma. All types of intracranial hemorrhage are associated with a worse prognosis, increased in-hospital mortality, and disability.[9] In the current study, 6 (85.7%) patients who had intracranial hemorrhage (seven patients) fell while riding camels on a surface that may be hardpacked earth causing severe head trauma.[911] The severity of trauma in such patients can be appreciated as 5 (71.4%) of those patients had their skulls fractured. Many patients who had intracranial hemorrhage had a history of loss of consciousness, which is similar to Yuksen et al. who showed that intracranial hemorrhage was significantly higher in patients with a history of loss of consciousness.[24]

Most of the patients had more than one type of intracranial hemorrhage similar to other studies on traumatic brain injuries. However, the only patient who died in the current study had subdural hemorrhage which is in keeping with the results of previous studies showing that subdural hemorrhage is associated with a higher probability of death than other intracranial hemorrhages.[25]

In the current study, 14 (35.9%) patients required surgical intervention; however, most of them were nonneurosurgical operations. Four (10%) patients suffered residual disability with different degrees. As shown by another study, even minor traumatic brain injury can result in disabilities that may include behavioral, mood, and other cognitive dysfunctions, especially in repetitive injury.[26] Therefore, it is of great importance to follow-up those injured patients and rehabilitation programs should be planned. Unfortunately, only 22 (56.4%) patients were followed up for a short period because most of them preferred to return to their home country after apparent recovery.[21]

We think that using robots instead of human in camel racing may help in decreasing the incidence of adult camel-related injuries as we have noticed in the current study. Furthermore, legislation for compulsory helmet usage by camel caregivers at farms may help in the prevention of serious head injuries.

Limitations and future study

We studied only hospitalized patients in our city. Many patients were treated in our emergency department without being admitted to the hospital, which highlights the need for a future prospective study on camel-related head injuries in the emergency department to better understand the magnitude of these injuries in our setting. Furthermore, the period of our study was between 2015 and 2021 and did not include the period before banning children and later human camel jockeys. Furthermore, our study was a retrospective study from a single hospital with a relatively small sample size. Despite these limitations, our study has provided useful information that can be used for the prevention of camel-related head injury and for educational programs for safety measures in handling camels at farms.

CONCLUSIONS

The majority of camel-related head injury occurred in camel caregivers at camel farms and can be considered a work-related injury. Careful handling of camels, especially during the summertime can reduce the toll of camel-related head injury and its serious consequences. None of the injured patients was wearing a helmet at the time of injury. Legislation for compulsory helmet usage by camel caregivers at farms may decrease the incidence of head injuries in those patients.

Research quality and ethics statement

This study was approved by the Research Ethics Governance Committee, Al Ain Hospital, Al Ain, Abu Dhabi, UAE (AAHEC-04-18-086). The authors followed applicable EQUATOR Network (http://www.equator-network.org/) guidelines during the conduct of this research project.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Acknowledgments

The authors wish to acknowledge Ms. Eiman Nasser Alshamisi, Senior Application Analyst, Al Ain Hospital and Mr. Norman A Avila, Trauma Program Manager, Sheikh Shakhbout Medical City, for their assistance in data extraction.

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Keywords:

Camel; head; injury

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