Head injury management in a resource limited setting – a prospective analysis of head injury patients and their outcomes in a provincial hospital in Papua New Guinea

Introduction

Head injury continues to be a common cause of morbidity and mortality worldwide in the 21st century despite advances in medical science and technology. The nations who continue to suffer the most are the developing countries where there is a heavy burden of trauma and very limited health resources available to manage head injury patients.

Developing nations like Papua New Guinea (PNG) are struggling to effectively manage head injury patients. PNG has a very high rate of trauma and violence and high numbers of head injury cases.¹ The introduction of the first computed tomography (CT) scanner in 2003 at Pacific International Hospital (PIH) and later at Port Moresby General Hospital (PMGH) in 2008 gave some hope for better outcomes for the patients in Port Moresby but not elsewhere.^2,3

At PMGH, there is a CT scanner, a neurosurgical team, specialist radiologists and a fairly well-equipped Intensive Care Unit (ICU) and Emergency Department (ED). Despite these advances in technology and facilities, there is still a high case fatality rate in PMGH.⁴

The provincial hospitals are managed by surgeons who are experienced in general surgery but less familiar with neurosurgery. Their management of head injury is centred on clinical assessment and management using Primary Trauma Care (PTC) and Emergency Management of Severe Trauma (EMST) principles, as well as their personal experiences in managing head injury cases. The provincial hospitals lack CT scanners, Magnetic Resonance Imagers (MRI) and even lack more basic facilities for investigations like X-rays and base line blood tests. These hospitals also lack ICU facilities and specialist neurosurgical units to care for their patients. They also have no trained neurosurgical nurses to look after head injury cases in the general surgical wards.

Literature

Globally, neurosurgical services are also limited with an estimated 49,940 neurosurgeons practising worldwide in 2019, in 198 countries, with between 0 and 59 neurosurgeons per 1,000,000 population.⁵ There are currently 33 countries in the world with no neurosurgeons and no neurological services.⁵ It has been estimated that there are around 5 million traumatic brain injuries (TBI) and spinal injury cases in low to middle income countries (LMICs) annually,⁶ which is a heavy burden of neurotrauma. Within the LMICs, poor neurosurgical services and the limited numbers of neurosurgeons mean that the goal of patient access within 4 h to a neurosurgically capable hospital is presently out of reach.⁶

There are a few reports of the situation in PNG. An early study by Liko and colleagues discussed the results of three prospective and retrospective studies.⁷ Their aim was to document the pathology and outcomes for 274 patients with head injuries admitted to Goroka General Hospital (GGH) between 1988 and 1991 and to PMGH in the periods 1984–1985 and 1992–1993. Head injuries were managed by general surgeons without CT scanning or intracranial pressure monitoring. There were 196 (72%) adults and 78 (28%) children; 195 were male and 79 females. The modes of injury were assaults (32%), motor vehicle accidents (49%) and falls (17%).⁷

The case fatality rate was 21% (57 of 274 cases). The fatality rates for patients with a Glasgow Coma Score (GCS) of 3–5, 6–8 and over 9 were 81, 21 and 3% respectively. Two patients died of infection complicating open depressed fractures. The case fatality rate for extradural haematoma was 20% and for subdural haematoma was 67%.⁷

More recently, Kaptigau and colleagues reported in 2007 that TBI has been responsible for 25–30% of surgical deaths in PMGH over the last 30 years, despite being responsible for only 5% of admissions.⁴ They also reported that between 2003 and 2004, there were 262 cases of TBI admitted to PMGH resulting in 31 deaths.⁴ 28 deaths were in the severe TBI category (GCS 3–8) and 3 in the moderate category (GCS 9–12). The case fatality rate of severe TBI was reduced from 60% to just below 30% over the period of 2 years. The authors concluded that the formation of a single unit managing TBI over the 2 years may have been one factor contributing to this improvement.⁴

The present study was undertaken to collect demographic data and to observe the primary and secondary outcomes for head injury patients in a resource limited provincial hospital (Alotau Provincial Hospital) in PNG.

The primary outcomes investigated were neurological status (GCS) upon discharge, disability rate (DR) upon discharge, length of hospital stay (LOHS) and case fatality rates (CFR) for each type of head injury. The features measured included the gender distribution, mean age, GCS upon admissions, mechanism of injury, causes of head injury, numbers of skull X-rays and CT scans performed, and operative versus conservative management.

Method

This was a prospective observational study done between January 2014 and June 2015 (1 year, 6 months). Patients were recruited at the emergency ward as they were diagnosed clinically and radiologically (X-rays only) as head injury patients.

The study was carried out at the Alotau Provincial Hospital (APH). APH has a high dependency unit (HDU) which observes and manages critically ill patients. There is no ICU or neurosurgical unit, no CT scanner, and no neurosurgical nurses available.

Results

Of the 67 cases recruited, 79% (n = 53) were males and 21% (n = 14) were females. The mean age of the patients was 20 ± 15 years. Table 1 gives a summary of the results of the study.

Discussion

Head injury continues to be a common cause of morbidity and mortality worldwide in the 21st century despite advances in medical science and technology. The outcome of head injury management results from primary neurotrauma itself, the availability of trained neurosurgeons, specialist neurosurgical units, neurosurgical intensive care units, trained neurosurgical nurses, and availability of neurosurgical equipment. In 2000, the global density of neurosurgeons was estimated at 1 per 230,000 population.⁵

By 2004, the World Health Organization estimated that there were approximately 33,193 neurosurgeons available worldwide including trainees.⁵ The current workforce density is 49,940 neurosurgeons worldwide.⁵ This discrepancy in the number of neurosurgeons and the growing population worldwide leads to on-going high mortality and morbidity worldwide for head injuries.

With the overwhelming burden of trauma and resource limitations in LMICs, head injury management continues to be a challenge for health care givers. Papua New Guinea as any other LMIC continues to have challenges in managing head injuries.^1,8

No provincial hospitals in PNG have neurosurgical units with specialised trained neurosurgeons and nurses to manage neurosurgical conditions including head injury cases. Alotau Provincial Hospital is a typical provincial hospital in PNG that has similar settings as other provincial hospitals in PNG. The head injury cases are managed by general surgeons and general nursing staff in the operating theatre and the general surgical wards.

From the results of this study, the mean age of the patients was 20 ± 15 years. The male gender is more affected than female gender. Liko and colleagues⁷ and Kaptigau and colleagues⁸ had similar findings at GGH and PMGH respectively for the mean age and gender distributions.^7,8 The number of blunt injuries exceeded penetrating injuries in this study and in the similar PNG studies.^7,8

Liko and colleagues looked at causes of head injuries and found that highest number of head injury in GGH and PMGH at that time was from MVA with 49%, followed by assaults with 32% and finally falls with 17%.⁷ In this study it was found that assaults (39%) and accidental falls (33%) were the most common causes of head injuries and not MVA (10%). The GCS upon admission showed that most of the head injury cases in this study fall in the mild (76%) to moderate (15%) group and few in the severe (9%) head injury group. However, the case fatality rate is highest in the severe head injury group (33%), as shown in the other studies.^4,8 Liko and colleagues showed that severe head injury had a CFR of 81%, moderate head injury of 21% and mild head injury of 3%.⁷ Kaptigau’s study also showed similar outcomes.⁴

This study revealed that the average length of hospital stay was 11 days and the disability rate was 5%, which other similar studies have not reported. The outcome of head injury management in this study was influenced by the GCS upon admission and by operative or conservative management (see Table 2). This further suggests that patients with low GCS upon admission and with delayed surgical intervention have poor outcomes.

The study failed to show the consequences of delays from time of injury to time of intervention, but a recent publication on global surgical health indicators for Milne Bay Province highlights three kinds of delays experienced by patients seeking safe, timely and affordable surgical, obstetric and anaesthetic care in Milne Bay Province: delays in deciding to travel to hospital, delays caused by travel times to hospital and delays before commencement of interventions after arrival at hospital.⁹ Of these three kinds of delay, the delay caused by travel times is clearest. With a population of 339,000, only 14% of this population has access within 2 h to APH, which is the only surgically capable local hospital.⁹ Head injury patients certainly have delays from time of injury to time of intervention in the province. A study on head injury and the delays to intervention must be conducted in the future to explore these delays in more detail and to determine the consequences of these delays.

Conclusion

We conclude that severe head injury continues to be a cause of high morbidity and mortality in resource limited settings in PNG due to primary injury to the brain parenchyma with the problem being exacerbated by resource limitations for effectively managing this group of patients in the provincial hospitals.

Limitations of the study

The main limitation of this study was the low number of subjects recruited. The results discussed would be more accurate if there were more subjects recruited into the study. The other limitation was that the study failed to explore the three kinds of time delays from injury time to intervention. These delays must be important factors for outcomes of head injury management.

Abbreviations