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April 2017, Volume 3, World J Med Images Videos Cases e
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World Journal of Medical Images, Videos and Cases
w w w . j o u r n a l o f m e d i c a l i m a g e s . c o m
Radical approach to vehicle passenger safety and some of the most striking
clinical trauma cases – from over 35-years of experience as a trauma surgeon
Andrzej Kochan
Introduction
I would like to make my final contribution to
medicine as a surgeon, having spent the last 35
years of my life working in very different
trauma settings. I have recently been diagnosed
with advanced metastatic pancreatic cancer
and I probably will last for maybe another
2 weeks. I have therefore asked the Editors to
allow me to include some of the interesting
photos from my line of work, the patients
I have been able to help or to save. Normally
I would have considered submitting them as
a couple of separate articles or cases, but since
my time is running out and I will not live that
long, this was really important to me. Hence,
the possibility was granted and it’s a special
way of saying goodbye to my profession, that
I dedicated my whole life to. Here is my short
bio:
I started off in the 1980’s as young surgeon in
Nowy Targ, a highland town in southern
Poland. There in Podhale, I had my first
encounters with injuries, mostly accidents as
well as soft tissue surgery. These were tough
times in communist Poland, with not so much
hope for the future. But my mentors always
knew I had to move on and gave me some
important hints and advice before my dreams
about leaving for the West came true. It took
time and patience before I was allowed to
travel to Austria, then USA and Canada.
Shortly thereafter I signed an attractive
contract as a trauma surgeon in Black River,
Jamaica (Fig.1).
Figure 1. On Black River Hospital grounds.
The real school of life for me begun on
Jamaica. Not only English-wise, but primarily
since I had to adapt to a new reality real fast –
one had to be much more independent and
aware of situations that could never be
encountered in Poland at that time. In Black
River I was able to develop my professional
trauma workshop and find real good colleagues
from America, who gave me some true
inspiration for the future years (Fig. 2-5).
ORIGINAL ARTICLE
April 2017, Volume 3, World J Med Images Videos Cases 2017 WJOMI
World Journal of Medical Images, Videos and Cases
w w w . j o u r n a l o f m e d i c a l i m a g e s . c o m
Figure 2. Next to a used Black River Hospital
ambulance.
Figure 3. After a long day’s work, time to relax
on one of Jamaican beaches, which was just
a bicycle ride away.
Figure 4. With colleagues in the operating
room.
Figure 5. Surprise photo taken during trauma
surgery in Black River Hospital.
Everything changed radically when my wife
and I signed a medical contract and moved to
the Republic of South Africa. We received free
accommodation in a big house, good salary
and additional benefits. But these were
Apartheid times, so no wonder. Initially
working in a long-forgotten, bush hospital for
April 2017, Volume 3, World J Med Images Videos Cases 2017 WJOMI
World Journal of Medical Images, Videos and Cases
w w w . j o u r n a l o f m e d i c a l i m a g e s . c o m
the black community in Maandagshoek1 (back
then in Lebowa Homeland) with my wife, the
anaesthetist, I came to realise that Jamaica was
nothing compared to Lebowa (Fig. 6-8).
Figure 6. Maandagshoek Casualty from the
back in 2009. Source: Stephen Korsman [1].
Figure 7. Maandagshoek swimming pool. The
pool was on HC Boshoff hospital grounds.
I remember my wife and kids cleaning the pool
and it was in perfect working order back then,
with crystal clear water. The photo was taken
in 2009. Source: Stephen Korsman [1].
1 Maandagshoek – means “Monday’s corner” in
Afrikaans.
Figure 8. Maandagshoek tennis court. The
court was on HC Boshoff hospital grounds,
nearby the swimming pool. I remember
playing tennis with my wife and son back then.
It wasn’t as overgrown and cracked as in this
picture from 2009. The tennis court and the
swimming pool were located in the vicinity of
the pastor’s house, all in lush greenery. Source:
Stephen Korsman [1].
Well, to be honest, understaffing, strikes, lack
of equipment and medication were only some
of the major problems along the way. There
were some other doctors working there too:
a couple from New Zealand, a lady from the
UK and a South African doctor. Rides to
school were 30 km one way. The dirt road was
often flooded with Maandagshoek being then
completely cut off. In addition, I soon learned
that a trauma surgeon was in South Africa also
a GP, an OB-GYN and a pathologist/forensic
specialist in one. One of the most common
procedures next to trauma surgery was in fact
delivering babies and also specialising in
C-sections. Already then, I also realized that
Africa can be a dangerous continent, not only
due to wild animal injuries but also owing to
cultural reasons. For some time, the local
April 2017, Volume 3, World J Med Images Videos Cases 2017 WJOMI
World Journal of Medical Images, Videos and Cases
w w w . j o u r n a l o f m e d i c a l i m a g e s . c o m
police were finding mutilated bodies of
children in the bush, with testicles, genitals and
eyes removed. For us, this looked like work of
a serial killer, especially that the children were
murdered in a similar fashion. I was asked by
the police to perform autopsies and it turned
out that they had been alive in most cases
when the perpetrator removed these organs.
Well to our surprise, the police did not
consider these crimes to be the work of a serial
killer, but they already knew these were acts
summoned by the witchdoctors – the so called
Sangomas. These traditional healers are not
licensed physicians but rather something
reminiscent of old tribal times. Unfortunately
some of the plant origin medicine concoctions
called muti had some additives in the form of
genitals or eyes. It was an easy way to
persuade the Sangoma’s “patient” to take lives
in order to save lives, e.g. by drinking the
concoction they were told by the witchdoctor
they will be getting rid of the HIV infection.
The only registered effect was often profuse
diarrhoea or renal failure, as I often helped
such “patients” in the ER.
Well, for a rather short period of time I worked
in Johannesburg, which at the time was like
a war zone. Gunshot wounds and machine gun
injuries, dousing victims, amputations and
traffic accidents, having an ethnic, political or
homicidal background, were a typical night
shift. It wasn’t rare for a whole minibus of
people to be shot at with an AK-47.
For more peace we moved to a small cozy
mining town of Phalaborwa in Transvaal,
where the children could have some perfectly
safe environment to attend very good schools.
At the time, we started off in the nearby black
township of Namakgale, where our work in the
hospital was a mixture of trauma and OB-GYN
procedures. Soon after, my wife and I were
offered jobs in the hospital in Phalaborwa,
where the duties also involved family
physician activities. Phalaborwa is also a gate
to the best known safari park in Southern
Africa – the Kruger National Park. At that time
there were refugees from the military conflict
in Mozambique crossing the game park to
make it to South Africa. Unfortunately some
didn’t make it past the lions and others needed
help of a trauma surgeon due to animal bites.
After some time, I moved on to work as
a surgeon in the town of Lydenburg and soon
became the Superintendent there, then
a Regional Superintendent. But life without
family was tough, and when Apartheid ended
and I was forced to retire, I decided to move
back to Phalaborwa. Unfortunately violence
and homicide spread real fast in the newly
democratic South Africa, so we decided to call
it quits and move back to the newly democratic
Poland.
Over the recent years in Poland, I continued to
work as a contract surgeon in the emergency
rooms in and around Cracow and some of the
photos also originate from my time working
again in my home country.
In this article, I would like to fit some facts and
my personal opinion on the traffic accidents
and related trauma, but most importantly their
prevention, and in the second part about
violence and non-traffic accident related
trauma.
April 2017, Volume 3, World J Med Images Videos Cases 2017 WJOMI
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Figures
Figure 9. Estimated road traffic death rate (per 100 000 population), 2013. Source: WHO [2].
Figure 10. Estimated number of road traffic deaths, 2013. Source: WHO [3].
April 2017, Volume 3, World J Med Images Videos Cases 2017 WJOMI
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w w w . j o u r n a l o f m e d i c a l i m a g e s . c o m
Figure 11. Road fatalities in the EU since 2001. The adopted Road Safety Programme which aims to
cut road deaths in Europe between 2011 and 2020 sets out a mix of initiatives for EU members,
focussing on improving vehicle safety, the safety of infrastructure and road users' behaviour. Source:
European Commission [4].
Traffic accidents
Road safety remains a major medical, societal,
psychological and economic issue. Traffic
related injuries are one of the main causes of
fatalities all around the globe, not only for
drivers but also for passengers, especially
those who don’t use seatbelts. Globally
speaking, low- and middle-income countries
have highest road traffic fatality rates per 100
000 population [5]. The continent with the
highest traffic death rate per population is
Africa [2]. In 2013, WHO reported Libya to
have the highest road traffic death rate per 100
000 population estimated to be 73.4 followed
by Thailand with 36.2 (Fig. 9) [2]. On the other
April 2017, Volume 3, World J Med Images Videos Cases 2017 WJOMI
World Journal of Medical Images, Videos and Cases
w w w . j o u r n a l o f m e d i c a l i m a g e s . c o m
hand, the country with the sum of most traffic
fatalities in the world was China with 261 367
deaths, followed by India with 207 551 and
Brazil with 46 935 deaths (Fig. 10) [3]. In the
United States, the CDC states that in 2014,
more than 2.3 million drivers and passengers
were treated in emergency departments as the
result of motor vehicle traffic crashes. As
many as 21 022 passenger vehicle occupants
died in car crashes. Most troubling is the fact
that over half of teens and adults who died in
crashes in 2014 were unrestrained at the time
of the crash [6].
Driving around Europe is relatively safe
nowadays. In 2011, more than 30,000 people
died on the roads of the European Union. If
you observe the evolution of road safety
regarding fatalities – thanks to many EU
improvements – it’s on a significant decrease
(Fig. 11). In 1991 there were 76 600 deaths
and in 2016 the number has dropped almost
3 fold to 26 100 [4]. Over the last few years,
most fatalities were reported for France, Italy,
Germany and Poland. In the same time period,
fatalities in Poland have dropped from 7 901 to
2 938. Although the total numbers are fewer,
Polish roads are twice as dangerous as German
and 3× more dangerous than UK roads,
considering per population statistics.
In my personal opinion, a lot of the traffic
accidents happen owing to human factors,
recklessness, specific personality or character
traits, often coming together with substance
abuse. The infrastructure is slowly improving,
the technical aspects of the vehicles are also
getting better. I do think that most traffic
accidents could be prevented with special
preventive measures. As to the preventive
measures: education, warnings and law come
as the most useful. Seatbelt use is also
improving, also when it comes to their use by
passengers. Back in the 80’s the vehicles were
mostly equipped with front seatbelts only.
Little did people realize that for all vehicle
occupants’ safety, it’s crucial for all
passengers, not only the driver, to buckle up.
Otherwise, the forces during collisions with
cars or trees are so great, that unrestrained
persons are launched from their seats either
through the windows or within the car, injuring
or killing other occupants, including children.
Below you may see a typical rear seat
passenger who did not use the seatbelt and was
thrown about the inside the vehicle when it
rolled. The 55 year old male suffered from
concussion, severe facial trauma, and vertebral
C6 fracture. The photos below show the
injuries during ER admission and workup (Fig.
12, 13).
Figure 12. The unrestrained passenger, with
severe facial trauma during the initial
debridement and suturing. Source: own
archive.
April 2017, Volume 3, World J Med Images Videos Cases 2017 WJOMI
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w w w . j o u r n a l o f m e d i c a l i m a g e s . c o m
Figure 13. The vehicle passenger was severely
concussed and suffered a C6 fracture. Source:
own archive.
In my opinion, radical informative campaigns,
that are currently used for smokers, could be
similarly applicable to (reckless) drivers as
warning roadside banners. You may see the
example I prepared, based on my own photo
archive (Fig. 14).
Violence-related and non-traffic accident
trauma
Violence and homicide related trauma shows
in statistics all around the globe and accounts
for around 10% of global injury-related deaths.
According to WHO, in 2012 there were an
estimated 475 000 murders. Four fifths of
homicide victims were men and 65% were
aged 15–49 years. Among women, partner
homicides account to 38% of all murders
compared to 6% of all murders among men
[7]. One of the main factors in homicide rates
is easy access to guns, with approximately half
of all homicides committed with a firearm. As
per WHO: “homicide and most forms of
interpersonal violence are strongly associated
with social determinants such as social norms,
gender inequality, poverty and unemployment,
along with other cross-cutting risk factors such
as easy access to, and misuse of, alcohol and
firearms” [7].
Even in highly-developed countries violent
crimes are not unusual. Trends in homicide
rates by WHO region in the years 2000–2012
show that altogether Americas had the highest
rate of homicides reaching 19.4 per 100 000
population. Especially in the low and middle-
income countries in this region, i.e. Central and
South America, the general rate peaked to 28.5
per 100 000 population. The probable reason is
the criminal organizations’ related violence,
corruption and political instability. On the
other hand, the WHO Western Pacific Region
had the lowest murder rate with 2.0/100 000
population [7]. See map in Fig.15.
April 2017, Volume 3, World J Med Images Videos Cases 2017 WJOMI
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Figure 14. Self-designed traffic awareness banner, based on cigarette smoking warning signs.
Figure 15. Homicide rates globally, according to United Nations Office on Drugs and Crime [8].
April 2017, Volume 3, World J Med Images Videos Cases 2017 WJOMI
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The highest mortality rates in the world due to
homicide per 100 000 population may be
found in:
1. Honduras (103.9),
2. Venezuela (57.6) and
3. Jamaica (45.1) [7].
Out of these countries I have worked in
Jamaica and also another arena of violence –
namely the 2nd
most violent country in Africa,
just after Lesotho, i.e. South Africa, with a
homicide mortality rate of 35.7 [7]. Some of
the trauma I treated, see Fig. 16-20.
Figure 16. Potential axe murderer victim, the man also suffered a severe blow to his hand, which slowed the
weapon, hitting him over the head, with less force. Despite the wound the victim was lucky to get away from
his assailant. Alcohol was also the substance involved.
April 2017, Volume 3, World J Med Images Videos Cases 2017 WJOMI
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To compare some of these figures, in 2012 the
Iraqi rate was 18.6, Russian was 13.1, and the
USA only 5.4. In Poland the same homicide
rate was 1.1, surprising but smaller than the
peaceful New Zealand with 1.2.
Countries with the lowest homicide mortality
rates are:
1. Luxembourg (0.2),
2. Japan (0.4) and
3. Iceland (0.6) [7].
Figure 17. Another similar axe injury to the head. The man’s hand and ear were injured which explains the changed
trajectory of the weapon, hitting him over the head partially with the blunt edge of the axe. The persons involved
were under the influence of alcohol and an argument erupted over some minor issue, like small debt or some long
forgotten quarrel.
April 2017, Volume 3, World J Med Images Videos Cases 2017 WJOMI
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Figure 18. Unsuccessful homicide victim with multiple deep knife cuts to the neck. Owing to him
resisting his attacker, he was able to avoid having his arteries slashed, which would have resulted in a
rather quick death. Despite heavy bleeding, all wounds were inspected and stitched back together.
Very surprisingly the same rate is sky high for
Greenland (sic!), at 13-25 it is often exceeding
the rate for Russia, with most of homicides due
to altercation and with a high percentage of
women killed [9]. On the other hand, Denmark
has a very low rate of homicide: 0.9 [7]. So
a weird conclusion that arises is that Greenland
is in the top 15 most violent countries by
homicide rate, ranking it at around Dominican
Republic and Haiti, and beating such countries
as Mexico, India, Thailand, Philippines, Sudan
etc [7]! In USA, the number of deaths due to
all homicides per latest data was 15 809 per
year. Firearm homicides included as many as
10 945 deaths. On the other hand, all
unintentional injury deaths in the USA
amounted to: 136 053, with unintentional fall
deaths (31 959), motor vehicle traffic deaths
(33 736) and unintentional poisoning deaths
(42,032)[10-11]. See also the enclosed Fig. 19.
April 2017, Volume 3, World J Med Images Videos Cases 2017 WJOMI
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Figure 19. Amputations and injuries to the upper limb, hands and fingers. Whether the injury relates to
tool shop, fireworks or motor vehicle accidents, most are in fact owing to the human factor, i.e.
improper long sleeve shirts, avoiding protective clothing, carelessness, recklessness or working under
the influence.
April 2017, Volume 3, World J Med Images Videos Cases 2017 WJOMI
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w w w . j o u r n a l o f m e d i c a l i m a g e s . c o m
Figure 20. Lower limb injuries, especially open
fractures, related to motor vehicle accidents.
Conclusions
Looking down the line of my lifetime work,
I am real glad to have helped so many victims
of accidents and violence-related trauma.
Having seen so many current global efforts in
place, many regions have become safe havens
for prolonging our lives. Unfortunately many
places around the globe, still resemble war
zones rather than habitable areas. Also, the
many military conflicts impede advancement
of such preventive measures.
I would like to thank all of my colleagues,
fellow physicians, surgeons, nurses and
medical personnel I shared many difficult and
happy moments in my career. I will not
mention any names since there were really so
many important persons in those last 35 years.
Special word of thanks must go to my loving
wife, who I am especially grateful to for all her
support and help, also now that I’m ill and
dying.
Last but not least, I would like to thank my
son, whom I’m very proud of. Not only is he
a much more decorated and renowned medical
doctor and academic teacher than I ever was,
but also the person that was, and still is, behind
the Polish Edition of the Sanford Guide to
Antimicrobial Therapy – the book that
I introduced to him on Jamaica in the 80’s and
the same one that I found useful in any
infection related to my line of work throughout
these years.
April 2017, Volume 3, World J Med Images Videos Cases 2017 WJOMI
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w w w . j o u r n a l o f m e d i c a l i m a g e s . c o m
References
[1] Panoramio. Stephen Korsman. Access valid on March 1,
2017: http://www.panoramio.com/user/3055628?photo_page=1
[2] World Health Organization. Road traffic deaths. Estimated
road traffic death rate per 100 000 population, 2013. Access
valid on March 1, 2017:
http://gamapserver.who.int/gho/interactive_charts/road_safety/ro
ad_traffic_deaths2/atlas.html
[3] World Health Organization. Road traffic deaths. Estimated
number of road traffic deaths, 2013. Access valid on March 1,
2017:
http://gamapserver.who.int/gho/interactive_charts/road_safety/ro
ad_traffic_deaths/atlas.html
[4] European Commission. Mobility and transport. Road Safety.
Statistics – accidents data. Access valid on March 1, 2017:
http://ec.europa.eu/transport/road_safety/specialist/statistics_en [5] World Health Organization. Global Health Observatory
(GHO) data. Road traffic deaths. Access valid on March 1, 2017: http://www.who.int/gho/road_safety/mortality/en/
[6] Centers for Disease Control & Prevention. Motor Vehicle
Safety. Access valid on March 1, 2017:
https://www.cdc.gov/motorvehiclesafety/seatbelts/facts.html
[7] WHO. Homicide. Access valid on March 1, 2017:
http://www.who.int/gho/publications/world_health_statistics/201
6/whs2016_AnnexA_Homicide.pdf?ua=1
[8] United Nations Office on Drugs and Crime. Global Study on
Homicide. Access valid on March 1, 2017:
https://www.unodc.org/gsh/
[9] Christensen MR, Thomsen AH, Høyer CB, Gregersen M,
Banner J. Homicide in Greenland 1985-2010. Forensic Sci Med
Pathol 2016;12:40-9.
[10] CDC. Assault or Homicide. Access valid on March 1, 2017:
https://www.cdc.gov/nchs/fastats/homicide.htm
[11] CDC. Accidents or Unintentional Injuries. Access valid on
March 1, 2017:
https://www.cdc.gov/nchs/fastats/accidental-injury.htm
Conflict of interest: none declared.
Authors’ affiliations:
Private Medical Practice
ul. Bliźniaków 32
32-089 Wielka Wieś
Cracow, Poland
Corresponding author:
†Dr Andrzej Kochan has sadly passed away shortly after
authorizing this article, still before it was published. All
questions may now be addressed to WJOMI Editorial Office.
We consider his death a big loss to the medical community.
To cite this article: Kochan A. Radical approach to vehicle
passenger safety and some of the most striking clinical trauma
cases – from over 35-years of experience as a trauma surgeon.
World J Med Images Videos Cases 2017; 3:e16-30.
Submitted for publication: 1 March 2017
Accepted for publication: 25 March 2017
Published on: 30 April 2017
ISSN: 2450-5773
World Journal of Medical Images, Videos and Cases