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Two years after coming under the Ministry of Health, the former Military Hospital, now the University Trauma Hospital, continues to face problems. Among the main ones are shortages of equipment and training for medical personnel. Dr. Agron Dogjani, a surgeon at the University Trauma Hospital, speaks with Shekulli.
Dogjani described the lack of appropriate training among some staff as extremely problematic, while also mentioning some of the equipment shortages doctors encounter in their work. He welcomed recent investment, but said it was not enough and must not stop here.
So many cases that intensive care stays full
“There are many cases, about 70 a day. Imagine: out of the 7 days in a week, intensive care is full on six,” says Dr. Dogjani. “40-42 percent of cases arriving at the University Trauma Hospital (SUT) are neurotrauma cases, about half of which require intensive care.
“Locomotor injuries (to the limbs) are much more frequent, while car accidents account for about 47 to 60 percent of cases by cause. Wounds from blades or firearms are also quite problematic and quite numerous, while falls from heights account for up to 25 percent.
In other countries, these accidents account for less than 10 percent. Measures must be taken in this respect, especially at work, so that these accidents do not happen.
“Generally, the patients who come here (to SUT) have multiple trauma, meaning that the injuries are not localized but also affect other areas. Injuries are rarely isolated.
These tend to be the injuries usually sustained in arguments, disputes, fistfights or attacks with blunt objects, or knife wounds with a single trajectory. Injuries in these cases are usually localized in the abdomen (belly) or thorax (chest).
“As for firearm injuries, we can say they generally involve 2-3 bullets, and the wounds cover different areas. In these circumstances, treatment is more complicated and takes longer, because priority is given to the more life-threatening wounds.”
Trauma care: inadequate training is a problem
Trauma care has 4 main pillars: prevention, care at the scene and transport, the hospital, and home care. Dr. Agron Dogjani explains that prevention comes first, something “we hardly do at all,” before moving on to the other pillars. “We need more awareness campaigns to prevent accidents and, especially, to educate people about how to help accident victims.
“Even when these campaigns are carried out, they are not linked to the Trauma Hospital but to other bodies or initiatives, such as the Red Cross or the ‘Donate blood!’ campaign, and so on. Schools have no teaching programs specifically devoted to this issue.
“Care at the scene is the essential element in treating trauma. We do nothing.
At best, on national roads, an accident victim may be brought in by a police vehicle. At worst, there is that uninformed solidarity: come on, get them into the car and rush to the hospital, without knowing that this kind of handling carries a risk of disability or even death.
“Without knowing that a cervical collar should be kept in the vehicle, because a collar fitted at the right time is the optimal solution in these cases. As far as care at the scene is concerned, we have finally reached the point of adopting the Anglo-Saxon trauma system, which entails skilled medical care provided by a paramedic (a paramedical professional).
Unlike the Franco-German system, which sends a qualified medical team (a doctor) to the scene, the Anglo-Saxon system sends a paramedic with their whole team. That team provides qualified medical first aid, preparing the injured person for transport to hospital.
“This system makes being a paramedic a profession. We still think a paramedic is simply there to carry the stretcher.
The Franco-German system envisages doing a great deal at the scene and little in the hospital. The Anglo-Saxon system is the opposite: little at the scene and a great deal in the hospital.
“But are we prepared for this system? The signs are good, but when will it actually be implemented? Meanwhile, accidents increase every day.
“As for the hospital, I can say that it lacks the infrastructure needed to receive emergency cases. Although it is the National Trauma Center, it has elements of a qualified medical service, but not the full service. The nurses working in trauma care have not graduated from a school for trauma, not because they do not want to, but because they have not undergone the relevant education specifically for trauma.
“It has been 20 years, and there is not a single trauma certificate. The trauma qualifications here can be counted on the fingers of one hand. The same situation extends to the surgical service.
“We have doctors who have made a great contribution over the years, but Albania still has no licensed trauma surgeon, as the United States does, for example, with 5 years of schooling in trauma surgery. We have acquired this expertise either through experience or through training and specialization, not through a specific course of study in this field.
Here, it is confused with orthopedic traumatology, which is one part of trauma and has its own importance because it covers injuries to the extremities. But how are we to cover chest trauma, abdominal trauma or head trauma?
“So we face this kind of emergency. The next link in the treatment chain is also problematic. Home care here remains at zero; it does not exist.
“A patient leaves hospital, and no one knows who will provide care at home. To some extent, there is a voluntary basis: some associations step in and cover it.
But for their own reasons, they are not permanent. We need a rehabilitation hospital; we have only a ward. Our doctors work like heroes, but they cannot cope with so many cases.”
About 80 percent of those treated have no coexisting diseases
“I do not know how it should be taken, as good luck or bad, but I look at it from the medical side,” says Dr. Dogjani, before explaining his observation. “More than 75-80 percent of the cases we treat are young people.
That is bad luck in a sense, but the good thing is that these cases have no coexisting diseases. Although these patients have suffered trauma, in most cases we are working with otherwise healthy patients.
“This makes their recovery more likely and faster. It would be different if we had older patients, patients with illnesses, for example diabetes or blood diseases, or, worse still, patients with malignant conditions: diseases that require very specific treatment and alter all the body’s parameters. Young patients have better physiological reserves and respond better to treatment than patients with chronic illnesses or older patients.”
The problems that make doctors pessimistic
“We need to establish some milestones so that proper trauma care can be built step by step in the future. What has happened up to now has happened, but from now on there must be order. No one without the right qualifications should be hired.
“It is not that no work is done here, or that there are no people working. Under the conditions we have, doctors from a Western hospital would not be able to do anything, not because they are incapable, but because they are not used to it. Intensive care is always full, and when a patient arrives, there is nowhere to put them.
“First of all, a patient comes from another district and is dumped here without an epicrisis (an accompanying medical summary describing the treatment given by the first doctors who took the patient on). So we have to ask the patient or their relatives what the previous doctor did, and this lack of information harms the patient. Then there is the equipment.
“The equipment that arrives, because equipment does arrive, is not accompanied by other equipment. For example, a new CT scanner is being installed. Wonderful!
“But a CT scanner should not stand alone. It must be accompanied by other infrastructure: a good ultrasound machine, a good video imaging system, and so on.
Then there is calibration. After a certain time, this equipment needs recalibration. That link is missing.
“We are completely behind in what is called interventional radiology, which allows many injuries to be treated without surgery, such as injuries to the liver, spleen and so on. Not only do we not have this service, there are not even projects to get us to that point. This makes us pessimistic as doctors.
“Operating rooms do not have a constant temperature. There are three main factors which, if measures are not taken to address them, can lead to a trauma patient’s death: hypothermia (temperature), metabolic acidosis and coagulopathy.
“People do not know it, but we cannot cover these factors. Temperature is not in our hands (the doctors’); it is in the state’s hands through investment. Measuring coagulopathy requires a measurement system that we do not have.
“Measuring metabolic acidosis requires an Astrup analyzer, a device we do not have. Imagine, we go into battle without any of these elements. For example, to have a patient’s coagulation profile in order, every patient arriving with trauma must have at least 10 units of blood.
“With 70 trauma cases coming here a day, can we have 700 units of blood? Impossible!”
So many cases that intensive care stays full
At the beginning of December, a scientific conference was organized specifically on trauma and emergency care, discussing possible solutions to the problems currently encountered in this field. In this respect, it was considered very helpful that the National Medical Emergency Center (also referred to as the ETC, Emergency Trauma Center) is expected to begin operating next year. Although Dr. Agron Dogjani has high hopes for this project, he says the first milestones need to be set and the effort must go beyond the institutional creation of the ETC.
“The project is in its infancy, but I hope something concrete will be done and that we will not settle for simply creating the institution, because the time has come to organize ambulance services by district, as the rest of the world does. We have major shortcomings in this respect. Tirana’s ambulances, for example, have to cover a very large area, both geographically and in population terms, and cannot cope with the many emergency cases.”
It should also be noted that in November, Health Minister Ilir Beqaj promised at least 20 new ambulances for this purpose.
Patients confused by trauma symptoms
After coordinating with SUT’s public relations office, we visited one of the trauma emergency department’s day rooms. The people in the room were generally confused about what had happened to them, while the medical staff had carried out the relevant diagnostic assessments. A middle-aged man complaining of severe abdominal pain told us he could not clearly remember how he had been injured, only that his relatives had brought him urgently to hospital.
In another bed lay an elderly man who, when we asked what was troubling him, replied confusedly that he had had all his tests. Another patient, a man in his fifties, told us he had had a pre-infarction episode and that afterward his legs had swollen terribly. What we observed was also confirmed by the doctors.
Generally, patients who have suffered trauma experience moments of confusion and, in most cases, do not display the precise symptoms. They therefore undergo detailed tests so that the right diagnosis can be reached.
Published in “Shekulli” on 26/12/2014