2.  RTA- 3445  ASSAULT – 2051  FALLS – 1373  BURNS – 913  GUNSHOT -172  RAPE – 60  SNAKE BITES – 31  HUMAN BITES- 30

3.  34yr old male referred from Machakos D.H. on 13/4/2013 with severe head injury and fracture femur GCS 9/15.  T.O.A 11am seen by the M.O 11am  Hx: Involved in RTA on 12/4/2013 L.O.C, Convulsions, Ottorrhea  O/E:Primary ad secondary survey done  Positive findings: GCS M-4 E-3 V-2 9/15 Blood noted on scalp, ottorrhea R, pupils BERL. Vitals 127/67 P.R

4.  M/S: Deformity on the R thigh (splinted) and L forearm(splinted)  Other systems normal.  Dx: SHI with # R femur/ L Forearm  Plan: CT scan Head and XRAYS (Booked and done at 2pm)  TBC/GXM/U/E/C  Prop up, Oxygen  Phenytoin 750mg loading, 250mg tds  Orthopaedic, neurosurgical and ICU

5. Orthopaedic review 5pm on 13/4/2013  GCS E-1 M-5 V-1 7/15 pupils BERL  Xray # proximal radius(closed)  Xray # R femur midshaft  CXR, pelvic xray- normal  Plan: cast radius (done), Traction of femur( thomas splint)

6. Neurosurgical review 5.25pm  Gcs 7/15 pupils BERL  CT scan: hypodense lession R frontal region  No intracerebral bleed  Conservative management as per Rx sheet  ICU review in view of Low GCS

7. ICU review 9.15pm  GCs 7/15 pupils BERL  Plan: Oxgen by non-rebreather mask 15L/min to be intubated once there is a free ventilator.  Patient intubated at 11.00pm

8.  Patient was on a stretcher in Acute room from 13 th to 15 th when he was admitted in Emergency ward (Lack of beds).  Currently patient admitted in Emergency ward.  ICU team reviews the patient daily.

9.  Delay in review of patients by the various disciplines.  Lack of teamwork in the management of the patients.  Lack of ownership of the patient.  Delay at the radiology department

10.  Lack of resources i.e. human, equipment (bed space, ventilators)  Congestion of casualty by catchment area.  Shortage of personnel especially nurses, porters and doctors.  Locum doctors- young doctors with minimal experience, lack of commitment.

11.  Trauma theatre and ward have not been in use for the past 5 years thus the trauma patients miss the golden hour to be attended to hence develop complications eg infections etc.

12.  Introduction of a trauma nurse coordinator who follows up on all trauma patients in casualty.  Have the sitting surgeon review the trauma patients immediately on arrival and decide on definitive management.  Have an x-ray room specifically assigned to accident and emergency department.

13.  Have trauma theatres available for trauma patients on 24hr basis i.e. with personnel posted to the theatres at A&E on 24 hr basis.  Consultants should be available in order to supervise SHOs and guide them in decision making.

14.  Strengthen existing triage system in Emergency Department  Train personnel on emergency ultrasonography and avail ultrasound machine for department for Focused Ultrasonography for Trauma patients.

15.  Adopt clinical protocols and adhere to them in a multidisciplinary approach to patient care.  ATLS training for both nurses and doctors working in the department.  Have more staff deployed to the department. Currently we have 103 nurses instead of 195 and 13 doctors instead of 36.