World Journal of Medical Images, Videos and CasesApril 2017, Volume 3, World J Med Images Videos...

April 2017, Volume 3, World J Med Images Videos Cases e

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World Journal of Medical Images, Videos and Cases

w w w . j o u r n a l o f m e d i c a l i m a g e s . c o m

Radical approach to vehicle passenger safety and some of the most striking

clinical trauma cases – from over 35-years of experience as a trauma surgeon

Andrzej Kochan

Introduction

I would like to make my final contribution to

medicine as a surgeon, having spent the last 35

years of my life working in very different

trauma settings. I have recently been diagnosed

with advanced metastatic pancreatic cancer

and I probably will last for maybe another

2 weeks. I have therefore asked the Editors to

allow me to include some of the interesting

photos from my line of work, the patients

I have been able to help or to save. Normally

I would have considered submitting them as

a couple of separate articles or cases, but since

my time is running out and I will not live that

long, this was really important to me. Hence,

the possibility was granted and it’s a special

way of saying goodbye to my profession, that

I dedicated my whole life to. Here is my short

bio:

I started off in the 1980’s as young surgeon in

Nowy Targ, a highland town in southern

Poland. There in Podhale, I had my first

encounters with injuries, mostly accidents as

well as soft tissue surgery. These were tough

times in communist Poland, with not so much

hope for the future. But my mentors always

knew I had to move on and gave me some

important hints and advice before my dreams

about leaving for the West came true. It took

time and patience before I was allowed to

travel to Austria, then USA and Canada.

Shortly thereafter I signed an attractive

contract as a trauma surgeon in Black River,

Jamaica (Fig.1).

Figure 1. On Black River Hospital grounds.

The real school of life for me begun on

Jamaica. Not only English-wise, but primarily

since I had to adapt to a new reality real fast –

one had to be much more independent and

aware of situations that could never be

encountered in Poland at that time. In Black

River I was able to develop my professional

trauma workshop and find real good colleagues

from America, who gave me some true

inspiration for the future years (Fig. 2-5).

ORIGINAL ARTICLE

April 2017, Volume 3, World J Med Images Videos Cases 2017 WJOMI



Figure 2. Next to a used Black River Hospital

ambulance.

Figure 3. After a long day’s work, time to relax

on one of Jamaican beaches, which was just

a bicycle ride away.

Figure 4. With colleagues in the operating

room.

Figure 5. Surprise photo taken during trauma

surgery in Black River Hospital.

Everything changed radically when my wife

and I signed a medical contract and moved to

the Republic of South Africa. We received free

accommodation in a big house, good salary

and additional benefits. But these were

Apartheid times, so no wonder. Initially

working in a long-forgotten, bush hospital for




the black community in Maandagshoek1 (back

then in Lebowa Homeland) with my wife, the

anaesthetist, I came to realise that Jamaica was

nothing compared to Lebowa (Fig. 6-8).

Figure 6. Maandagshoek Casualty from the

back in 2009. Source: Stephen Korsman [1].

Figure 7. Maandagshoek swimming pool. The

pool was on HC Boshoff hospital grounds.

I remember my wife and kids cleaning the pool

and it was in perfect working order back then,

with crystal clear water. The photo was taken

in 2009. Source: Stephen Korsman [1].

1 Maandagshoek – means “Monday’s corner” in

Afrikaans.

Figure 8. Maandagshoek tennis court. The

court was on HC Boshoff hospital grounds,

nearby the swimming pool. I remember

playing tennis with my wife and son back then.

It wasn’t as overgrown and cracked as in this

picture from 2009. The tennis court and the

swimming pool were located in the vicinity of

the pastor’s house, all in lush greenery. Source:

Stephen Korsman [1].

Well, to be honest, understaffing, strikes, lack

of equipment and medication were only some

of the major problems along the way. There

were some other doctors working there too:

a couple from New Zealand, a lady from the

UK and a South African doctor. Rides to

school were 30 km one way. The dirt road was

often flooded with Maandagshoek being then

completely cut off. In addition, I soon learned

that a trauma surgeon was in South Africa also

a GP, an OB-GYN and a pathologist/forensic

specialist in one. One of the most common

procedures next to trauma surgery was in fact

delivering babies and also specialising in

C-sections. Already then, I also realized that

Africa can be a dangerous continent, not only

due to wild animal injuries but also owing to

cultural reasons. For some time, the local




police were finding mutilated bodies of

children in the bush, with testicles, genitals and

eyes removed. For us, this looked like work of

a serial killer, especially that the children were

murdered in a similar fashion. I was asked by

the police to perform autopsies and it turned

out that they had been alive in most cases

when the perpetrator removed these organs.

Well to our surprise, the police did not

consider these crimes to be the work of a serial

killer, but they already knew these were acts

summoned by the witchdoctors – the so called

Sangomas. These traditional healers are not

licensed physicians but rather something

reminiscent of old tribal times. Unfortunately

some of the plant origin medicine concoctions

called muti had some additives in the form of

genitals or eyes. It was an easy way to

persuade the Sangoma’s “patient” to take lives

in order to save lives, e.g. by drinking the

concoction they were told by the witchdoctor

they will be getting rid of the HIV infection.

The only registered effect was often profuse

diarrhoea or renal failure, as I often helped

such “patients” in the ER.

Well, for a rather short period of time I worked

in Johannesburg, which at the time was like

a war zone. Gunshot wounds and machine gun

injuries, dousing victims, amputations and

traffic accidents, having an ethnic, political or

homicidal background, were a typical night

shift. It wasn’t rare for a whole minibus of

people to be shot at with an AK-47.

For more peace we moved to a small cozy

mining town of Phalaborwa in Transvaal,

where the children could have some perfectly

safe environment to attend very good schools.

At the time, we started off in the nearby black

township of Namakgale, where our work in the

hospital was a mixture of trauma and OB-GYN

procedures. Soon after, my wife and I were

offered jobs in the hospital in Phalaborwa,

where the duties also involved family

physician activities. Phalaborwa is also a gate

to the best known safari park in Southern

Africa – the Kruger National Park. At that time

there were refugees from the military conflict

in Mozambique crossing the game park to

make it to South Africa. Unfortunately some

didn’t make it past the lions and others needed

help of a trauma surgeon due to animal bites.

After some time, I moved on to work as

a surgeon in the town of Lydenburg and soon

became the Superintendent there, then

a Regional Superintendent. But life without

family was tough, and when Apartheid ended

and I was forced to retire, I decided to move

back to Phalaborwa. Unfortunately violence

and homicide spread real fast in the newly

democratic South Africa, so we decided to call

it quits and move back to the newly democratic

Poland.

Over the recent years in Poland, I continued to

work as a contract surgeon in the emergency

rooms in and around Cracow and some of the

photos also originate from my time working

again in my home country.

In this article, I would like to fit some facts and

my personal opinion on the traffic accidents

and related trauma, but most importantly their

prevention, and in the second part about

violence and non-traffic accident related

trauma.




Figures

Figure 9. Estimated road traffic death rate (per 100 000 population), 2013. Source: WHO [2].

Figure 10. Estimated number of road traffic deaths, 2013. Source: WHO [3].




Figure 11. Road fatalities in the EU since 2001. The adopted Road Safety Programme which aims to

cut road deaths in Europe between 2011 and 2020 sets out a mix of initiatives for EU members,

focussing on improving vehicle safety, the safety of infrastructure and road users' behaviour. Source:

European Commission [4].

Traffic accidents

Road safety remains a major medical, societal,

psychological and economic issue. Traffic

related injuries are one of the main causes of

fatalities all around the globe, not only for

drivers but also for passengers, especially

those who don’t use seatbelts. Globally

speaking, low- and middle-income countries

have highest road traffic fatality rates per 100

000 population [5]. The continent with the

highest traffic death rate per population is

Africa [2]. In 2013, WHO reported Libya to

have the highest road traffic death rate per 100

000 population estimated to be 73.4 followed

by Thailand with 36.2 (Fig. 9) [2]. On the other




hand, the country with the sum of most traffic

fatalities in the world was China with 261 367

deaths, followed by India with 207 551 and

Brazil with 46 935 deaths (Fig. 10) [3]. In the

United States, the CDC states that in 2014,

more than 2.3 million drivers and passengers

were treated in emergency departments as the

result of motor vehicle traffic crashes. As

many as 21 022 passenger vehicle occupants

died in car crashes. Most troubling is the fact

that over half of teens and adults who died in

crashes in 2014 were unrestrained at the time

of the crash [6].

Driving around Europe is relatively safe

nowadays. In 2011, more than 30,000 people

died on the roads of the European Union. If

you observe the evolution of road safety

regarding fatalities – thanks to many EU

improvements – it’s on a significant decrease

(Fig. 11). In 1991 there were 76 600 deaths

and in 2016 the number has dropped almost

3 fold to 26 100 [4]. Over the last few years,

most fatalities were reported for France, Italy,

Germany and Poland. In the same time period,

fatalities in Poland have dropped from 7 901 to

2 938. Although the total numbers are fewer,

Polish roads are twice as dangerous as German

and 3× more dangerous than UK roads,

considering per population statistics.

In my personal opinion, a lot of the traffic

accidents happen owing to human factors,

recklessness, specific personality or character

traits, often coming together with substance

abuse. The infrastructure is slowly improving,

the technical aspects of the vehicles are also

getting better. I do think that most traffic

accidents could be prevented with special

preventive measures. As to the preventive

measures: education, warnings and law come

as the most useful. Seatbelt use is also

improving, also when it comes to their use by

passengers. Back in the 80’s the vehicles were

mostly equipped with front seatbelts only.

Little did people realize that for all vehicle

occupants’ safety, it’s crucial for all

passengers, not only the driver, to buckle up.

Otherwise, the forces during collisions with

cars or trees are so great, that unrestrained

persons are launched from their seats either

through the windows or within the car, injuring

or killing other occupants, including children.

Below you may see a typical rear seat

passenger who did not use the seatbelt and was

thrown about the inside the vehicle when it

rolled. The 55 year old male suffered from

concussion, severe facial trauma, and vertebral

C6 fracture. The photos below show the

injuries during ER admission and workup (Fig.

12, 13).

Figure 12. The unrestrained passenger, with

severe facial trauma during the initial

debridement and suturing. Source: own

archive.




Figure 13. The vehicle passenger was severely

concussed and suffered a C6 fracture. Source:

own archive.

In my opinion, radical informative campaigns,

that are currently used for smokers, could be

similarly applicable to (reckless) drivers as

warning roadside banners. You may see the

example I prepared, based on my own photo

archive (Fig. 14).

Violence-related and non-traffic accident

trauma

Violence and homicide related trauma shows

in statistics all around the globe and accounts

for around 10% of global injury-related deaths.

According to WHO, in 2012 there were an

estimated 475 000 murders. Four fifths of

homicide victims were men and 65% were

aged 15–49 years. Among women, partner

homicides account to 38% of all murders

compared to 6% of all murders among men

[7]. One of the main factors in homicide rates

is easy access to guns, with approximately half

of all homicides committed with a firearm. As

per WHO: “homicide and most forms of

interpersonal violence are strongly associated

with social determinants such as social norms,

gender inequality, poverty and unemployment,

along with other cross-cutting risk factors such

as easy access to, and misuse of, alcohol and

firearms” [7].

Even in highly-developed countries violent

crimes are not unusual. Trends in homicide

rates by WHO region in the years 2000–2012

show that altogether Americas had the highest

rate of homicides reaching 19.4 per 100 000

population. Especially in the low and middle-

income countries in this region, i.e. Central and

South America, the general rate peaked to 28.5

per 100 000 population. The probable reason is

the criminal organizations’ related violence,

corruption and political instability. On the

other hand, the WHO Western Pacific Region

had the lowest murder rate with 2.0/100 000

population [7]. See map in Fig.15.




Figure 14. Self-designed traffic awareness banner, based on cigarette smoking warning signs.

Figure 15. Homicide rates globally, according to United Nations Office on Drugs and Crime [8].




The highest mortality rates in the world due to

homicide per 100 000 population may be

found in:

1. Honduras (103.9),

2. Venezuela (57.6) and

3. Jamaica (45.1) [7].

Out of these countries I have worked in

Jamaica and also another arena of violence –

namely the 2nd

most violent country in Africa,

just after Lesotho, i.e. South Africa, with a

homicide mortality rate of 35.7 [7]. Some of

the trauma I treated, see Fig. 16-20.

Figure 16. Potential axe murderer victim, the man also suffered a severe blow to his hand, which slowed the

weapon, hitting him over the head, with less force. Despite the wound the victim was lucky to get away from

his assailant. Alcohol was also the substance involved.




To compare some of these figures, in 2012 the

Iraqi rate was 18.6, Russian was 13.1, and the

USA only 5.4. In Poland the same homicide

rate was 1.1, surprising but smaller than the

peaceful New Zealand with 1.2.

Countries with the lowest homicide mortality

rates are:

1. Luxembourg (0.2),

2. Japan (0.4) and

3. Iceland (0.6) [7].

Figure 17. Another similar axe injury to the head. The man’s hand and ear were injured which explains the changed

trajectory of the weapon, hitting him over the head partially with the blunt edge of the axe. The persons involved

were under the influence of alcohol and an argument erupted over some minor issue, like small debt or some long

forgotten quarrel.




Figure 18. Unsuccessful homicide victim with multiple deep knife cuts to the neck. Owing to him

resisting his attacker, he was able to avoid having his arteries slashed, which would have resulted in a

rather quick death. Despite heavy bleeding, all wounds were inspected and stitched back together.

Very surprisingly the same rate is sky high for

Greenland (sic!), at 13-25 it is often exceeding

the rate for Russia, with most of homicides due

to altercation and with a high percentage of

women killed [9]. On the other hand, Denmark

has a very low rate of homicide: 0.9 [7]. So

a weird conclusion that arises is that Greenland

is in the top 15 most violent countries by

homicide rate, ranking it at around Dominican

Republic and Haiti, and beating such countries

as Mexico, India, Thailand, Philippines, Sudan

etc [7]! In USA, the number of deaths due to

all homicides per latest data was 15 809 per

year. Firearm homicides included as many as

10 945 deaths. On the other hand, all

unintentional injury deaths in the USA

amounted to: 136 053, with unintentional fall

deaths (31 959), motor vehicle traffic deaths

(33 736) and unintentional poisoning deaths

(42,032)[10-11]. See also the enclosed Fig. 19.




Figure 19. Amputations and injuries to the upper limb, hands and fingers. Whether the injury relates to

tool shop, fireworks or motor vehicle accidents, most are in fact owing to the human factor, i.e.

improper long sleeve shirts, avoiding protective clothing, carelessness, recklessness or working under

the influence.




Figure 20. Lower limb injuries, especially open

fractures, related to motor vehicle accidents.

Conclusions

Looking down the line of my lifetime work,

I am real glad to have helped so many victims

of accidents and violence-related trauma.

Having seen so many current global efforts in

place, many regions have become safe havens

for prolonging our lives. Unfortunately many

places around the globe, still resemble war

zones rather than habitable areas. Also, the

many military conflicts impede advancement

of such preventive measures.

I would like to thank all of my colleagues,

fellow physicians, surgeons, nurses and

medical personnel I shared many difficult and

happy moments in my career. I will not

mention any names since there were really so

many important persons in those last 35 years.

Special word of thanks must go to my loving

wife, who I am especially grateful to for all her

support and help, also now that I’m ill and

dying.

Last but not least, I would like to thank my

son, whom I’m very proud of. Not only is he

a much more decorated and renowned medical

doctor and academic teacher than I ever was,

but also the person that was, and still is, behind

the Polish Edition of the Sanford Guide to

Antimicrobial Therapy – the book that

I introduced to him on Jamaica in the 80’s and

the same one that I found useful in any

infection related to my line of work throughout

these years.




References

[1] Panoramio. Stephen Korsman. Access valid on March 1,

2017: http://www.panoramio.com/user/3055628?photo_page=1

[2] World Health Organization. Road traffic deaths. Estimated

road traffic death rate per 100 000 population, 2013. Access

valid on March 1, 2017:

http://gamapserver.who.int/gho/interactive_charts/road_safety/ro

ad_traffic_deaths2/atlas.html

[3] World Health Organization. Road traffic deaths. Estimated

number of road traffic deaths, 2013. Access valid on March 1,

2017:

http://gamapserver.who.int/gho/interactive_charts/road_safety/ro

ad_traffic_deaths/atlas.html

[4] European Commission. Mobility and transport. Road Safety.

Statistics – accidents data. Access valid on March 1, 2017:

http://ec.europa.eu/transport/road_safety/specialist/statistics_en [5] World Health Organization. Global Health Observatory

(GHO) data. Road traffic deaths. Access valid on March 1, 2017: http://www.who.int/gho/road_safety/mortality/en/

[6] Centers for Disease Control & Prevention. Motor Vehicle

Safety. Access valid on March 1, 2017:

https://www.cdc.gov/motorvehiclesafety/seatbelts/facts.html

[7] WHO. Homicide. Access valid on March 1, 2017:

http://www.who.int/gho/publications/world_health_statistics/201

6/whs2016_AnnexA_Homicide.pdf?ua=1

[8] United Nations Office on Drugs and Crime. Global Study on

Homicide. Access valid on March 1, 2017:

https://www.unodc.org/gsh/

[9] Christensen MR, Thomsen AH, Høyer CB, Gregersen M,

Banner J. Homicide in Greenland 1985-2010. Forensic Sci Med

Pathol 2016;12:40-9.

[10] CDC. Assault or Homicide. Access valid on March 1, 2017:

https://www.cdc.gov/nchs/fastats/homicide.htm

[11] CDC. Accidents or Unintentional Injuries. Access valid on

March 1, 2017:

https://www.cdc.gov/nchs/fastats/accidental-injury.htm

Conflict of interest: none declared.

Authors’ affiliations:

Private Medical Practice

ul. Bliźniaków 32

32-089 Wielka Wieś

Cracow, Poland

Corresponding author:

†Dr Andrzej Kochan has sadly passed away shortly after

authorizing this article, still before it was published. All

questions may now be addressed to WJOMI Editorial Office.

We consider his death a big loss to the medical community.

To cite this article: Kochan A. Radical approach to vehicle

passenger safety and some of the most striking clinical trauma

cases – from over 35-years of experience as a trauma surgeon.

World J Med Images Videos Cases 2017; 3:e16-30.

Submitted for publication: 1 March 2017

Accepted for publication: 25 March 2017

Published on: 30 April 2017

ISSN: 2450-5773


http://www.panoramio.com/user/3055628?photo_page=1

http://gamapserver.who.int/gho/interactive_charts/road_safety/road_traffic_deaths2/atlas.html

http://gamapserver.who.int/gho/interactive_charts/road_safety/road_traffic_deaths2/atlas.html

http://gamapserver.who.int/gho/interactive_charts/road_safety/road_traffic_deaths/atlas.html

http://gamapserver.who.int/gho/interactive_charts/road_safety/road_traffic_deaths/atlas.html

http://ec.europa.eu/transport/road_safety/specialist/statistics_en

http://www.who.int/gho/road_safety/mortality/en/

https://www.cdc.gov/motorvehiclesafety/seatbelts/facts.html

http://www.who.int/gho/publications/world_health_statistics/2016/whs2016_AnnexA_Homicide.pdf?ua=1

http://www.who.int/gho/publications/world_health_statistics/2016/whs2016_AnnexA_Homicide.pdf?ua=1

https://www.unodc.org/gsh/

https://www.cdc.gov/nchs/fastats/homicide.htm

https://www.cdc.gov/nchs/fastats/accidental-injury.htm

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