RTA- 3445 ASSAULT – 2051 FALLS – 1373 BURNS – 913 GUNSHOT -172 RAPE – 60 SNAKE BITES – 31 HUMAN BITES- 30

34yr old male referred from Machakos D.H. on 13/4/2013 with severe head injury and fracture femur GCS 9/15.

T.O.A 11am seen by the M.O 11am Hx: Involved in RTA on 12/4/2013 L.O.C,

Convulsions, Ottorrhea O/E:Primary ad secondary survey done Positive findings: GCS M-4 E-3 V-2 9/15

Blood noted on scalp, ottorrhea R , pupils BERL. Vitals 127/67 P.R

M/S: Deformity on the R thigh (splinted) and L forearm(splinted)

Other systems normal. Dx: SHI with # R femur/ L Forearm Plan: CT scan Head and XRAYS (Booked and

done at 2pm) TBC/GXM/U/E/C Prop up, Oxygen Phenytoin 750mg loading, 250mg tds Orthopaedic, neurosurgical and ICU

Orthopaedic review 5pm on 13/4/2013 GCS E-1 M-5 V-1 7/15 pupils BERL Xray # proximal radius(closed) Xray # R femur midshaft CXR, pelvic xray- normal Plan: cast radius (done), Traction of

femur( thomas splint)

Neurosurgical review 5.25pm Gcs 7/15 pupils BERL CT scan: hypodense lession R frontal region No intracerebral bleed Conservative management as per Rx sheet ICU review in view of Low GCS

ICU review 9.15pm GCs 7/15 pupils BERL Plan: Oxgen by non-rebreather mask

15L/min to be intubated once there is a free ventilator.

Patient intubated at 11.00pm

Patient was on a stretcher in Acute room from 13th to 15th when he was admitted in Emergency ward (Lack of beds).

Currently patient admitted in Emergency ward.

ICU team reviews the patient daily.

Delay in review of patients by the various disciplines.

Lack of teamwork in the management of the patients.

Lack of ownership of the patient. Delay at the radiology department

Lack of resources i.e. human, equipment (bed space, ventilators)

Congestion of casualty by catchment area. Shortage of personnel especially nurses,

porters and doctors. Locum doctors- young doctors with minimal

experience, lack of commitment.

Trauma theatre and ward have not been in use for the past 5 years thus the trauma patients miss the golden hour to be attended to hence develop complications eg infections etc.

Introduction of a trauma nurse coordinator who follows up on all trauma patients in casualty.

Have the sitting surgeon review the trauma patients immediately on arrival and decide on definitive management.

Have an x-ray room specifically assigned to accident and emergency department.

Have trauma theatres available for trauma patients on 24hr basis i.e. with personnel posted to the theatres at A&E on 24 hr basis.

Consultants should be available in order to supervise SHOs and guide them in decision making.

Strengthen existing triage system in Emergency Department

Train personnel on emergency ultrasonography and avail ultrasound machine for department for Focused Ultrasonography for Trauma patients.

Adopt clinical protocols and adhere to them in a multidisciplinary approach to patient care.

ATLS training for both nurses and doctors working in the department.

Have more staff deployed to the department. Currently we have 103 nurses instead of 195 and 13 doctors instead of 36.