This is a small, compact book designed for trauma system development in low and middle income countries. The book is modeled after the optimal criteria developed by the American College of Surgeons. It is a nice little book, a gem in the rough, but not perfect. In the first paragraph of Section 2, the authors emphasize the importance of prevention. Unfortunately, most trauma is due to bad behavior, which makes it problematic in developing cohesive prevention programs. The authors also state, ‘‘The improved survival and functional outcome among injured patients in developed countries comes from high-cost equipment and technology.’’ This might be true of such technology as computed tomography scans, which has dramatically changed the ability to diagnose and treat appropriate injuries. The greatest advances in developed countries, however, have been the development of systems, including commitment and training of general surgeons to be the primary caregivers for major injury. The same could be achieved in low and middle income countries if the education and training of surgeons were to be a primary priority. To avoid some of the problems that have occurred recently in developed countries, the general surgeon could be trained to do emergency orthopedics and neurosurgery. In Section 2, the authors also deal with essential health services and whether there is evidence that organization of trauma services leads to better outcomes. Such evidence is available for developed countries, and one of the authors of these guidelines has contributed evidence that it also works in low and middle income countries. The authors acknowledge that prehospital care is extremely important, but it is not addressed in this book. It would be easy to add a small section in forthcoming editions. The major strength of these guidelines is the resource matrix concept and the designation of priorities. The matrix consists of the central resources, desirable resources, possibly required resources, and irrelevant resources. This allows for flexibility and utility when developing a trauma system in almost any country. In the section on respiratory distress, the authors do not discuss the possibility of using oxygen generators instead of oxygen tanks. This has been used with some success in military operations and is relatively inexperience. One of the shortcomings of the book is that the authors still include the pulse rate in the assessment and management of shock. Cannon, during World War I (corroborated by a study measuring blood volumes during World War II), showed that tachycardia has no role in diagnosing the depth of shock, although the quality of the pulse is useful. In the table on circulation and shock, the authors list colloids as desirable. The Cochrane report does not support this, and because colloids are more expensive, it seems to this reviewer that crystalloid and blood should be emphasized. In the section on the management of head injury, the authors have unfortunately disregarded evidence from developing countries where intracranial mass lesions are successfully managed by general surgeons with the same outcome as neurosurgeons. I think this would be important to stress in such a book based on the scarcity of neurosurgeons and the long distances to tertiary centers. Under neck injury, one of the resources should be the recognition of ‘‘hard signs.’’ This practice is inexpensive, and is easily learned. Under management of chest injuries, the authors state that most chest injuries, whether blunt or penetrating, are managed without surgical intervention. This is no longer a truism, particularly in some developing countries, where high-velocity rifle injuries are becoming the norm. Guidelines are not a substitute for recognizing wound ballistics. A table such as that designed by Robin Cook for the International Red Cross could be useful. In the section on diagnosis and monitoring, the authors have not included one of the simpler tests that may be useful in diagnosis and management of patients following injury: the dipstick to measure urine specific gravity and presence of blood. In summary, the guidelines for essential trauma care comprise an excellent start for health planners in low and middle income countries. The matrix system is simple, utilitarian, and pragmatic. Hopefully, in future editions they will correct some of the minor faults. World J. Surg. 29, 662 (2005) DOI: 10.1007/s00268-005-1097-3
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May 1, 2007
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