Road Traffic

Road Traffic Digest No 6
How to reduce fatalities on Indian roads?

and
What should be the road map to follow in
the present scenario

www.tsunamionroads.org
Instead of discussing the ideal management for road
accidents, here we will first consider What is practically possible
in the present scenario of road traffic management in our
country.
In broad terms reduction in fatalities can be
achieved by two ways

[A] By Preventing road accidents to occur
and if occur
[B] By providing better trauma care to accident victims
In the present and next couple of digests we would consider the post
crash management. After that we would take up the issue How to prevent
Road Accidents in our lives.
24% victims can be saved by SIMPLE trauma care

46% injured can be saved by ADVANCED trauma care

Rest 30% injured CAN NOT be saved even by the best
available medical facility in the world !!
As the impact of the accident is so severe
that death occurs on the spot immediately or within
few minutes before medical facilities arrive.
Prevention is the only answer for this group !!
Some UNIVERSAL facts about results of Trauma care:
Some more reasons to believe why prevention
is so important?

1.Prevention is much more cost effective as compared
to post crash management [especially in India].

2. In India, we have world class medical facilities for
most other diseases, though this quality care may not
be accessible to all. However, trauma care for
accident victims is still not available to even those
who can afford it on their own.
Trauma care in
India
I am due in
202@#??*
3. At present trauma care is in embryonic stage
in India. In a country where health budget
is 1-2% of GDP, good trauma care on roads
is a distant dream for at least next 20 years.
The trauma care for accidents victims can be divided into
two:

[1] Pre-hospital care and
[2] Treatment or care in hospitals.

[I] Pre-Hospital Trauma Care

What should we do at the accident site ??

This basically includes an attempt to rescue the injured
from the accident site, call for help, provide first aid and
arrange for transfer of injured for definitive care.
So let us consider what is the best trauma care we can
offer for accident victims in the present circumstances in
our country.
Step 1: Rescue the injured from the accident site
It means to remove injured person/persons who are trapped either inside
or under a vehicle or lying on road so that much-needed first aid can be
given and also to prevent any further trauma by other moving vehicles .
Dont forget to place this sign
to safeguard yourself
Five policemen including station in-
charge, while rescuing two accident
victims, were run over by a truck and
died on the spot [Sitapur, 22nd June 2011
Who can do this rescue job?
This rescue work can be initiated by any one not
necessarily from a medical background like:
Co-passengers
Bystanders
Other drivers
Dhaba/roadside restaurant owners
Police
Villagers, etc.
We dont expect trained paramedics or an ambulance
immediately [within few minutes] so role of people just
mentioned or first responders, even if they are not trained,
cannot be overemphasized.
Step 2: Call for emergency help
Make a call for an ambulance or for patrolling or
local police and to relatives of the injured by
checking his identity.
In India, calling the police to accident site is equally
important as that of an ambulance. The reason being the public
reaction may be hysterical after accident, so controlling the crowd
becomes important in such situations.
Planning ahead for danger can mean the
difference between life and death
Following precautions ensure better aid:
Keep vital information like name, address, important phone
numbers, readily available
Information of medical insurance [e.g. contact details of
insurer, hospitals on panel in that region, etc]
Blood groups, history of major illness and drugs being used for
it. Number of some ambulances and hospitals of that area, etc

Where to keep this information?
This information can be kept inside ones purse or along with documents of
vehicle or as sticker on dashboard or in mobile phone

Any one including you, co-passengers or rescuers can easily
use it to provide medical treatment within the golden hour.

[2] Keep An Emergency Kit: Besides a first-aid kit and tool
kit, some more items may be of great help in such situations:
Pointed iron rod to unlock the jammed door is
especially helpful when it catches fire or
plunges into water
Large screwdriver, pair of pliers,
rubber hammer
Emergency light, Fire extinguisher,
flash light, extra batteries, etc.
Step 3:

Till formally trained paramedical personnel
arrive, start providing some first aid:
If no ambulance or health facility is expected at the site then
dont wait or waste time. Arrange some transportation to
rush towards a hospital.
About First Aid

It is the initial medical help to an injured person at accident site and
during transfer till a definitive medical help is available or casualty
recovers

The purpose of first aid is to prevent deterioration in condition
and to maintain vital functions during this period
The first hour after trauma is called golden hour. Even in this
golden hour it is the initial four to five minutes [called
platinum period] that are very critical

First Aid in the first hour after accident can increase
the survival chances by 70%
Dont hesitate in such a situation on the premise of your limited knowledge and
fear of causing more harm to the injured.
Remember only the fact that your intentions are the
best, you are the only one around to help him and something
is always better than nothing and this something can really
go a long way. [
]
Here we will discuss more about dealing with serious injuries
as we all are used to dealing with minor wounds or cuts.

The description about first aid that follows is
basically for non-medicos or primary responders
[commuters, bystanders, etc]
Steps for First Aid
A. Ensure vital functions: Cardiopulmonary resuscitation

The very first priority of first aid is to ensure a clear Airway,
Breathing and Circulation [ABC]
Steps for CPR
1. Make the person lie on some hard
surface on his back.
CPR involves two activities: chest compressions and mouth-to-
mouth breathing [one after every four chest compressions]
Look for consciousness, breathing and pulse of injured. If there
is no respiration and heart/pulse then start a Cardiopulmonary
resuscitation (CPR) immediately
2. Place the heel of one hand over the center
of persons chest, between the nipples. Place
your other hand on top of the first hand. Keep
your elbows straight and position your houlders
directly above your hands.
3. Use your upper body weight (not just your
arms) as you push straight down on (compress)
the chest for two inches. Push hard and push
fast: give two compressions per second, or
about 120 compressions per minute.
Observe closely
On full screen
4. Put your palm on the
persons forehead and gently tilt
the head back. Then with the other
hand, gently lift the chin forward
to open airway.
6. - - and breathe into the mouth for one
second. [one rescue breath after every
four chest compressions]
5. Kneel next to the persons neck and
shoulders. Pinch the nose shut - - - -
If there is one more person available to help,
he can perform this mouth to mouth respiration
If the chest rises, give a second rescue breath. If the
chest doesnt rise, repeat it. Continue CPR until there are
signs of movement or until emergency medical personnel
take over
If you do not want a contact with victim, you may
use a small piece of stiff rubber pipe to push the
breath in.
Some times a large number of injured
may be there and more hands may be
required to provide this first aid or to
help paramedical staff
B. Choking or respiratory obstruction
Choking or blockage of airway or throat is a frequent
complication after an accident. It is caused by aspiration of :

1. blood trickling down from the mouth or nose
2. broken teeth or artificial dentures
3. Recently ingested food
4. Any food items present in the mouth at the time of
accident [pan, gutkha, chewing gum, etc]
These above items in mouth can kill us instantly !!
The chances of death increase if the injured is unconscious, as he is not able to
spit or cough it out

On the other hand, automobile companies
are encouraging dashboard dining by
providing modifications like cup/bottle
holders, folding tables or even small
refrigerators. We feel this is a wrong trend
and has to be discouraged.

This not only complicates condition of
victim after accident but is also an
important cause of distraction during
driving leading to actual accidents. Not only
this, hyperglycemia due to excess calories
may lead to dozing behind the wheel !!
Are these automobile cos. aware of
these facts??
If it is a complete obstruction owing to presence of some
material inside the wind pipe or trachea, then use the
Heimlich maneuver where you give five quick upwards thrusts
over the upper abdomen above the umbilicus.

If still airway is not cleared and the person remains
choked, then start cardiopulmonary resuscitation (CPR).
Sometimes chest compressions used in CPR may dislodge the
material from the trachea.

What should we do in case of choking?
To clear the air passage, turn the injured on to his
side with head end little low so that blood or
other contents come out with gravity. It will also
relieve any tongue fall that frequently aggravates
chocking in an unconscious patient.
The best way is to apply direct pressure over the
wound by hand using a piece of clean cloth
Please note, usually it requires more pressure
than we expect, so instead of fingers, use
heel of palm to apply pressure. Usually
bleeding takes 4-5 minutes to stop.

Do not look frequently to confirm whether
bleeding has stopped or not as this may
dislodge fresh clot that has just formed.
Instead, wait patiently. Sometime it may require
15-20 minutes.
C. Bleeding Wounds: what to do?

In case of bleeding from limbs or head, you can apply a tight
bandage or clean cloth around it for sustained pressure.

If still bleeding does not stop then instead of removing the dressing,
apply more over it and try to rush the victim to hospital.
If there are multiple wounds, priority should be given to the
ones that are bleeding profusely
D. Fracture
Fracture is the most common type of injury in accidents [40-50%]
When to suspect:
[a] A fracture or dislocation of a limb is suspected
when there is abnormal mobility, limb deformity,
A grating feeling due to movement between two
fractured segments of bone.

[b] In case of fracture, even a slight movement
causes severe pain.
What to do in case of fracture?:
Immobilization or splinting of fractured limb is the
basic aim during first aid of fractures.

One should not try to correct alignment of fracture as
this may cause injury to underlying vessels & nerves.
Instead do splinting with the help of some available
wooden stick or metallic bar and apply a gentle
pressure bandage.
Sometimes the underlying fractured segments of
bone can come out after piercing the skin. Cover this
exposed part with a clean cloth or bandage.
In cases of total detachment or amputation of a limb:
Sometimes it is possible to join amputated part
with the body with the help of microvascular
surgery. Collect this severed body part in a clean
polythene bag but do not add water [if available
normal saline may be used] and place this bag in
another bag with cold water.
The remaining wound on the body from which a part
has been severed may bleed profusely. In such cases tie a
tourniquet just above the site of the amputation.
Open wounds of the chest can affect respiration severely by
sucking in air through the wound. It can be minimized by covering
the wound with a piece of polythene and putting a bandage over it.
This may help to reduce air being sucked into the chest.

In case of abdominal wounds the intestines may come out.
Dont try to push them back into place. Cover the wound
with a wet clean cloth dressing.
Do not remove large or deeply embedded objects from wounds.

Do not probe penetrating wounds or attempt to clean them at this point.

At present our principal concern is to stop bleeding
F. Chest or Abdomen injury
G. Head Injury
FACTS:
[1] It is the most common cause of mortality in road accidents
and responsible for 75% deaths among two wheeler drivers.
When to suspect a head injury:
It should be suspected when there is a wound over scalp and there are
associated symptoms like convulsions, evidence of paralysis or weakness
in limbs, deterioration in the level of consciousness, state of confusion,
bleeding from the nose or ear.
[2] Among the total neurotrauma admissions, head injury sustained
during road accidents constitutes about 60%.

[3] Even if you survive the head injury; there may be significant
neurological deficit, enough to make life miserable for you and
your family. So never underestimate the role of a helmet .
What to do in case of head injury ?
Patient should be kept in a lying-down position preferably
turned to one side. In this position vomitus or bleeding
from nose or mouth would come outside and chances
of aspiration in to respiratory passages would be
minimized.

Keep a watch for any breathing irregularities, loss of
consciousness or any convulsions.
In case of bleeding from inside the ear, instead of
plugging the ear, get the injured to lie down with injured
ear facing down. If there is bleeding from nose, this could
be from injury inside nose or due to head injury. A
bleeding from nasal injury usually stops when you pinch
the tip of nose for a few minutes while bleeding due to
head injury rarely responds to this maneuver.
Cover the wound over the head and the exposed brain
matter if any by bandage or a clean piece of cloth
Spine Injuries
Road accidents contribute to 45-50% of total spinal injurie
There are several examples where ignorance of this fact OR an
overenthusiastic approach has caused complete paralysis that
was not there after the accident.
Please note, when someone has a spinal injury, any additional movement
may dislocate a vertebra causing further damage to the spinal cord and
thereby can paralyse the lower part of body permanently.
What NOT to do in case of spine injuries
[b] In case he needs CPR, do not tilt head back when
attempting to open airway. Instead, place your fingers on the
jaw on each side of the head. Lift the jaw forward.
[a] DO NOT move, bend, twist, or lift a person's head or body even a
little bit, unless it is absolutely necessary [e.g. if his surroundings or the
vehicle in which he is trapped is not safe] Otherwise, wait for trained
medical personnel to arrive and handle the situation.
[c] Do not remove a helmet if a spinal injury is suspected.

What to do in spinal injuries:
If a board in not available, you can remove a long seat of a bus or a top of
some wooden bench from roadside dhaba/restaurant for this purpose
Thus the basic aim is that we do not hurt him more during resuscitation or
shifting, by keeping the person immobile and safe until medical help arrives.
[a] For keeping a person absolutely immobile, place a tape across his forehead,
and secure person to a board to keep head, neck, and back areas from
moving AT ALL.
Place rolled towels on both sides of neck and body. While
doing this, don't interfere with person's breathing. If
necessary, use both of your hands, one on each side of
person's head to keep the head from moving.
[b] If at all you need to move a person [e.g.
choking by vomiting or blood], at least two
people are needed. One person should be
stationed at his head, other at person's
side.
[c] Extreme precautions are necessary while shifting such patients for
definitive treatment. There are three possible stages in shifting where
abnormal movements can occur. These are:
[i] Rescuing the injured from vehicle to nearby place
[ii] taking from this place to ambulance. [iii]
taking him from ambulance to inside the hospital building
Move the person in the manner you roll a carpet i.e. whole body
is moved as a single block without any twisting or tangential
movements. Keep the person's head, neck, and back in a
straight line while you roll him onto one side
[II] Transportation of Victim to
Hospital
The next course of action is transport of victim from accident site to an
appropriate nearby hospital.

If the ambulance team has already joined the rescuers, it will make an
arrangement for transport, once the job of giving first aid is completed

If no ambulance services are expected to reach there and condition of
patient is deteriorating, some other transport may be arranged

For this a van, bus or any vehicle having a long seat is preferred where
there is enough space to keep the patients back straight and
accompanying persons are able to care for him.
Care inside ambulance

Whether to feed or not:
This is a very common mistake that we allow injured to drink water
etc or keep on pouring water into their mouths. It is safer not to
give the victims anything to eat and drink. Even if person complains
of thirst, give nothing by mouth. This is to protect patient from
vomiting in case he needs anesthesia for some surgery or if he
suffers a head injury. In an unconscious patient this water can go
into his respiratory passages and can choke him.
Sometimes owing to presence of a crowd,
inadequate light outside and better facilities
inside van, you feel more comfortable in giving
first aid inside ambulance
Paramedical staff can continue remaining part of the resuscitation
procedures or can administer other therapy required .e.g. IV fluid line,
oxygen, drugs, etc.
Cases with simple wounds
or fractures or where
condition of injured is
quite stable can be taken
to smaller centres
The pre-hospital care team should assess the severity of
injury properly so that they can transfer the injured to an
appropriate hospital according to the level of care
required.
In cases of serious or
multiple injuries , opt for a
higher centre even if it is
situated a little farther
Choose a correct destination
To avoid confusion, the team should know about all government
and private hospitals in that region, not only in terms of distances
but also regarding level or quality of care available. This will avoid
an unnecessary referral from one centre to the other.

Sometimes cases of serious or multi-system injuries, requiring quality
care with urgent surgical intervention, are first carried to small centres
where nothing more than first aid is available and ultimately has to be
taken to a higher centre causing loss of precious time
There should be no confusion on the way!
If the ambulance team is in contact with a hospital, it can inform them
well in advance about the specialist/specialists who would be needed
and also for any preparations to be made when patient arrives at the
hospital.

Even blood grouping can be done on the way so that the particular
blood group can be arranged in advance.
The ambulance drivers should avoid over-speeding as this may not only be a
cause of another accident but also the bumpy ride can be risky for injured.
Be in touch with hospital
A large number of trauma victims can be saved by a
timely and correct emergency surgical intervention. We
cannot deny important role of many minor BUT extremely
useful procedures for saving trauma cases e.g.
[III] Treatment at hospital
[1] Primary or Emergency care
Inter costal intubation
Endotracheal intubation
treating shock with blood and IV fluids
These minor procedures can be performed with low priced equipment or
facility, e.g. laryngoscope, endotracheal tubes, resuscitation bag, airways,
suction apparatus, etc.
It has been seen that many times it is not the availability of funds
that is a problem but the lack of an organized approach or drill or
lack of will instead!
The spectrum of trauma among accident victims varies
widely involving a wide range of specialities [orthopaedic,
general surgery, neurosurgery, thoracic and vascular,
plastic surgery, etc].
[2] Specialized care
The definitive care is purely a job of the specialists, so a detailed
description is not necessary here. However, pre-hospital care is
really an area where every one of us can contribute, that is why
this has been discussed here in greater detail
This was about the practical approach towards road
accident victims that we all should know and follow in
present circumstances in our country.
I n the next digest we will discuss about the ground reality or
present Status of trauma care in I ndia.
or
What are the practical problems in management of road
accident victims
Remember accidents can happen any time any where and not
surprisingly at mid night in a lonely area where you dont expect
any help.

Even a little knowledge can be of immense help. So please go
through it seriously or join some first aid demo in your city.
The description given here is basically for non-medicos or
primary responders [commuters, laymen, bystanders, etc] until
trained paramedical staff comes and joins them.

A detailed discussion of these actual measures from the point
of view of paramedical staff is beyond the scope of these digests
and need some formal training with detailed text.

You have received this message from 'Tsunami on Roads
Organization' as a part of an awareness campaign against
road traffic hazards. If you find merit in this message, please
forward it to your contacts

From
Conscious Citizens, India
[www.tsunamionroads.org]

For previous digests please visit: http://www.tsunamionroads.org/rtd.html
or http://www.scribd.com
To receive such digests in future please inform at
consciouscitizensindia@gmail.com
Jai Hind

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Road Traffic Digest No 6

How to reduce fatalities on Indian roads?

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