Nizwa Hospital faces several challenges in orthopedics care including increased demand, higher expectations, and its remote geographic location. This leads to issues like delays in transferring unstable trauma patients to facilities that can provide definitive care. Establishing a formal trauma system and improving specialty availability could help address gaps. Collaboration between researchers, educators, and local health centers may help standardize protocols, upgrade remote facilities, and facilitate safer patient referrals and transfers.

1. Challanges in Orthopedics
Nizwa Hospital
• DR Dinesh Dhar
• Senior Specialist Orthopedics , Nizwa
Hospital

2. Why Challenges?
• Increase Health awareness among
people
• Increased demand for better health
facilities
• Litigations
• Increase in number of senior citizens
• Higher Consumer expectations
• Geographic Location of Nizwa

3. Nizwa at Cross Roads

7. Everyone pays injury costs
THE ANNUAL NATIONAL COST OF INJURY
IS ESTIMATED TO BE
$ 188 BILLION

8. Objectives
Trauma Care
Clinical transfer
issues
System Issues

9. The Golden hour
Early trauma deaths can be impacted by
rapid evaluation and resuscitation
A well- organized
trauma system
can prevent 20-
40% of
deaths

10. Trauma Systems
Increased time to definitive care
associated with higher mortality rates
Trauma system development reduces
risk of death from injury
Sampalis JS et al. Journal of Trauma, 1999
Nathens AB. J Trauma, 2000

11. Five C’s of
Trauma Care
Comprehensive
Communication
Consistency
Cost
Commitment

12. CHALLENGES OF OUR
PRACTICE SETTING
Geographic distances
Health delivery
system under stress
Supportig orthopedic
speciality lacking in
peripheral centres
GP s not trained to
deal with trauma pts

13. Specialty Shortages (Availability)
Neurosurgery
Vascular surgeons
Trauma Surgeons
Trained Nursing personnel

14. Consequences of Shortages
Lack of experience with trauma care
Shifting of patients for definitive care
Overloading Tertiary Resources
Delay in definitive treatment

16. Clinical Transfer Issues
Unstable trauma transfers
Transfers for technology
Delays in Transfer
Spinal Injuries
Vascular Injuries

17. Necessary Workup prior to
Transfer
Hx and PE. IV Access
GCS < 8 = Intubate pt X-
rays ???
Do not delay transfer for
extensive (complete) x-ray
evaluation !

18. Unstable Trauma Transfers
Case 1 Hx:
50 yr male head on collision. ? Pulse at the
scene. CPR started
Arrived at ED, no pulse, V Fib Defibrillated
x1, Sinus tachycardia. BP 70/ Pupils mid
positioned and fixed
CXR = normal; FAST negative; abdomen
soft. Multiple fractures
Call for Transfer? NH ??

19. Outcome
NH called
In ambulance pt. develops V fib
Defibrillation x5, ACLS protocols
Arrives NH , full CPR
Pronounced after 5 minutes
Appropriate transfer??

20. CASE HISTORY 2.
27 Y.O. MALE
PEDESTRIAN
STRUCK BY CAR
TRANSPORTED BY EMS
AMBULANCE
TO LOCAL HOSPITAL.

21. V.S. BP 70/50 P= 60
R= 22
GEN: NON RESPONSIVE
CHEST: CLEAR AND SYMETRIC
BS +
ABD: TENDER LOWER
ABDOMEN
PELVIS: TENDER ; LARGE
SCROTAL HEMATOMA
RECTAL: NORMAL ,
NO LONG BONE FRACTURES

22. RESUSITATION /
EVALUATION
6 LITERS CRYSTALLOID; 2UNITS
PC
HYPOTENSIVE/ TACHYCHARDIA
CXR =NEG. PELVIS = S-I
DISRUPTION , WIDENED
SYMPHYSIS
ANALGESICS GIVEN FOR PAIN
TRANSFERRED TO NH 5 HRS
AFTER INITIALARRIVAL

23. ARRIVAL NH:
BP = 80/ P = 115 RR = 12
CARDIOPULMONARYARREST
ASYSTOLIC ,
NO RESPIRATIONS
CODE BLUE : INTUBATED ;
RESUSITATED
ABG = 6.72/60/565

24. RESUSITATION /
EVALUATION
8.5 LITERS CRYSTALLOID; 6
UNITS O-NEG , 4 UNITS FFP
HGB = 8.2 K+ = 4.5 BUN/CR
=12/2.1
PT/PTT = 19/66 ABG = 7.07/38/556
CXR, C-SPINE, PELVIS
CYSTOGRAM, FAST = NEG CT
HEAD = NEGATIVE

25. DEFINITIVE TREATMENT:
EXTERNAL FIXATOR APPLIED
ANGIOGRAM: BLEEDING LT
HYPOGASTRIC ARTERY BRANCHES
EMBOLIZATION

26. Case 3
• 32 yrs old male MVA Type 3c open fracture
left proximal femur with injury to femoral
vessels on weekend.
• Initial Resuscitation done , Tertiary centres
contacted in Muscat for Vascular injury
• Nobody ready to take patient for non
availability of vascular surgeon.
• Finally Transferred to Sohar hopsital but too
late for vascular repair .
• End Result Amputation . System Failure?
• All Vascular surgeons on leave at same time ?

27. Delay in Transfer
Issues
Accessing entry into the Level I / 2 center
Available resources for transport
Non availability of blood products
No facility for ventilation / intubation
Mass RTA victims which need evacuation

28. Ambulance Service
Availability
Level of training
Leaving the community “uncovered”
Undue delay waiting for Driver ,
Escort personnel?

29. Advanced Response
Team
Air Transports
Khareef season
Interhospital
Transports
Trauma ~ 80%
Scene Calls 10%

30. Khareef season
• Testing timer for NH Surgical Services
• 2017 three Major Accidents with sudden
influx of mass accident victims
• Stretches our services to maximum
• No secondary care hospital between
Nizwa and Salalah over 900 km .
• Only Haima hospital in middle with no
Surgical or blood bank services .

32. System Issues
Technology
Referrals
Orthopedic Logistics
Subspeciality Training

33. Technology Changes
CT scan details the
injury
CT Available in all
hospitals
Newer generations
with increased detail
and speed
MRI non availability in
Level 2 hospitals
C- arm fluroscopy
availability in all
orthopedic centres

34. Technology Changes:
Interventional radiology: embolization
angio, stents
Pelvic Trauma
– embolization
Arterial injury
– Angio with endovascular stent
Spinal Cord injury / Ligament Injuries
Knee
–MRI Facility

35. Potential Impact
Delays in secondary triage Patient
safety
–Increased radiation exposure
–Delays in emergent care
Cost
–Patients billed twice
–Burden to entire trauma system

36. Referrals
RefWewe

37. Orthopedic Logistics
• Shortage of Basic Trauma Implants
• Delay in procurement of Implants for trauma
and other orthopedic services
• Only one dedicated OT for trauma and
elective cases .
• New Generation Implants not available
• Common Surgical OPD and Wards
• Constant Shortage of beds .
• Subspeciality Training ?
• Physiotherapy Services under strain

38. H
Pressures on Orthopedic
Services
Personnel Shortages
–Surgeons , Physio.
–Nurses , OT staff
Bed capacity/availability
Disaster Management
Implants Procurement
Trauma Sevices

39. More than 4 million
potential years of
productive life are lost
annually due to injury,
exceeding losses from
heart disease, cancer &
stroke COMBINED
Why we should not so
much excited

40. In order to succeed, regional trauma
centre development is must .It
should have adequate facilities and
trained personnel.

41. Collaboration of Researchers, Educators,
Scholars & Teachers (CREST)
Opportunities for improvement:
CREST?
Educational outreach
Facilitate referral process
Standardized protocols
Upgrading remote health
Centres ?
Improve communication

42. TAKE HOME MESSAGE:
The Moral Dilemma :
• Technology is neutral – it is neither good
nor evil
• It is up to us to breathe the moral and
ethical life into these technologies
• And then apply them with empathy and
compassion for each and every patient

44. Thanks