Elizabeth Khadija Tissingh: Improving trauma outcomes in the Democratic Republic of Congo

The Democratic Republic of the Congo (DRC) is large, beautiful and resilient. It also has a tremendously sad history and is still fragile. It is a country with huge potential - rich in natural resource, geographically strategic and a people with a strength of character only seen in places where life is incomprehensibly difficult. It is a country one cannot help but be touched by.

The Kongo Central province (formerly Bas Congo) in the southwest DRC has known relative political stability for decades but the health needs of its population are still not met. The main arterial route running through Kongo Central connects the Atlantic port cities of Boma and Matadi with the capital Kinshasa. The burden of trauma due to road traffic collisions along this route is significant. Current medical facilities are ill equipped to deal with the number of injuries and to provide effective care for trauma patients.

Trauma in the DRC must be seen in the context of trauma in Sub-Saharan Africa. Trauma-road traffic injuries, falls, inter-personal violence, and work place injuries are a daily reality in Sub-Saharan Africa. It is estimated that injuries are the eighth leading cause of death in Sub-Saharan Africa and the 10th leading cause of healthy life years lost (1). And yet trauma is not high on the list of development priories. The international community involvement in Sub-Saharan Africa still largely focuses on infectious diseases and maternal and child health. The non-communicable disease agenda and the global surgery agenda are gaining prominence. The trauma agenda is still waiting in the wings.

The King’s Kongo Central Partnership (KKCP) is a long-term partnership between the King’s Centre for Global Health and Health Partnerships in London (a joint centre between King’s College London (University) and King’s Health Partners (Academic Health Science Centre including Guy’s and St Thomas’, King’s College Hospital and the South London and Maudsley Trust) and the Kongo Central Ministry of Health in the DRC. The long-term goal of the KKCP is to improve health outcomes in the area of trauma through trauma system development, clinical care, training and research working with the Hopital General de Réference de Kinkanda in Matadi and the Université Joseph Kasa Vubu (UKV) in Boma.

The year I am spending in the DRC is part of the wider KKCP work. I have been involved with the KKCP since its beginning in 2013 and have taken a year out of my trauma and orthopaedic training to live and work in the Kongo Central province. The purpose of my year is to observe, listen and learn. I am here to understand the current context within which trauma happens and how it is treated. I am here to ask the question: how do you improve trauma outcomes?

Information gaps around trauma

There are still many information gaps around trauma in sub-Saharan Africa. Which baseline metrics do we measure? How do we measure change? Which public health policies improve outcomes? Are trauma registries effective in improving trauma outcomes? Which clinical interventions, applicable to the DRC context, are effective and cost-effective? Does training healthcare workers in trauma care improve outcomes? These questions are defining my time here in the DRC, even as we start to work to improve trauma outcomes. The work I am doing in partnership with UK volunteers and Congolese colleagues is in four main areas: clinical care, trauma system development, training and research. The work is part of the long-term partnership with an emphasis at this early stage on an understanding of the challenges, solutions and the collection of baseline metrics.

Small practical measures have been introduced to improve hand hygiene and facilitate day-to-day clinical care: hand washing facilities have been installed in the orthopaedic ward, a white board has been hung to facilitate planning for theatre cases, storage space has been created for patient notes and x-rays. A small library has been made available for the junior doctors. The orthopaedic team at the hospital includes two medical students, five junior doctors, two senior surgeons and two senior orthopaedic nurses. All clinical work - for a trauma and orthopaedic inpatient case load averaging 50 patients - is done with Congolese colleagues.

A weekly clinical programme has been established in the orthopaedic department with clinics, theatre lists and teaching ward rounds on set days. In addition, a weekly multi-disciplinary team meeting has been established for all complex trauma and orthopaedic cases. This is attended by clinicians form both Kinkanda and other centres in Matadi. A clinical protocol for the management of open fractures has been developed with Kinkanda clinicians. Current principles of good practice have been adapted to be applicable to the local context to create a protocol that is readily utilizable. It is available in the emergency department, on the wards and in theatres.

A trauma registry has been developed and piloted at Kinkanda hospital. A paper registryadapted from francophone registries already in use- was introduced in 2015 and piloted for a year. This has been evaluated and, following consultation, the registry has been amended. A decision has been made within the trauma registry team to move to electronic data collection and a PC will be installed in the ED room for this purpose. It is hoped that the registry will be expanded to other centres in the province.

A trauma registry has been developed and piloted at Kinkanda hospital. A paper registryadapted from francophone registries already in use- was introduced in 2015 and piloted for a year. This has been evaluated and, following consultation, the registry has been amended. A decision has been made within the trauma registry team to move to electronic data collection and a PC will be installed in the ED room for this purpose. It is hoped that the registry will be expanded to other centres in the province.

Research is ongoing in the following areas: trauma registries in LMICs, qualitative work on trauma priorities in LMICs and the LMIC trauma training evidence base. This work is being done with Congolese doctors, King’s students and a wider international group including links at the University of Toronto, McGill, Oxford and the Lancet. As part of the work to collect baseline metrics, data from the pilot phase of the trauma registry is being evaluated and the WHO “Situational Analysis to Assess Emergency and Essential Surgical Care” tool has been used to assess the trauma preparedness at Kinkanda.