Are We Safe On the Karakoram Highway?

Dr. Atif Ali

7^th June 2016, yet another unfortunate accident on KKH claimed lives of 5 people including the driver. The four of the unfortunate deceased belong to same village of Hunza and were closely related. A Father’ Ali Ahmed (45 yr) his young daughter Faiza (19), relatives,  Saeed (20yr) and Aziza ( 19) . This unfortunate family was travelling home from Islamabad to Gilgit on vacations and met an accident near Kohistan. Was it a mechanical fault, like busted tire which led to this accident or was it result of over speeding, untrained driver or driver falling asleep due to tiredness? There are rumors that the said Driver was a first timer on KKH and wasn’t familiar to deadly & deceptive turns of mountainous roads. Since there are no survivors or eye witnesses of this accident all we can do is speculate and assume.

One might find this irrelevant now to find the cause of this accident’ as it wouldn’t alter the sorrow and pain of the grieving families’ nonetheless it is important subject equally so that in future such accidents could be avoided. This accident has triggered me to write down what has been on my mind for last 2 month ; about safety protocols on road and First Aid. As I see vans, coasters and buses full of tourists every day driving up the mountains and every time they pass by me at top speed ‘this thought gives me a chill that what if any unfortunate event takes place? Do we have appropriate infrastructure, facilities and expertise to deal with mass causalities? This small town where I am posted as Medical Officer’ suffered a mass casualty situation couple of months back, taking lives of 8 people of same family. I have just heard about the horrors of that accident from locals. As there was no road access to referral hospital at that time and the THQ lacked number of facilities ‘many of them died from moderate injuries. This article is intended to create general awareness among public, especially youth regarding RTA’s  & things that we ignore on road before riding behind the steering wheels. I would categorize the article under two broader aspects i.e

1. General facts about RTA ( Road traffic accident) & importance of safety measures & “Golden Hour” in the outcome of injury related to RTA’s.
2. Realistic Analysis of health facilities of Gilgit Baltistan & Practical solutions to reduce the fatality of accidents.

A-Facts about RTA  (3^rd Leading Cause of Death Worldwide)

RTA is leading cause of disability and death in first 4 decades( up to 40 yrs)  of life worldwide. It is also 3^rd most common cause of death. According to a report published in 2000 5 million people got killed as result of injuries and approximately 1.2 million among them died of RTA. Hundreds of thousands who survived experience long term or permanent disabilities, profound change in lifestyle, costly medical expenses & long term psychological issues ‘ regardless of gender, race & economic status.

It is saddening fact that more than 90% of world wide death due to Injuries occur in low and middle income countries. There are multiple reasons for this difference in outcome of injuries between developed countries and underdeveloped countries. To understand this we must first look deeper into the whole concept of trauma and trauma management.

1-Importance of Time and Concept of “Golden Hour”.

Time is the one of the most important factor which determines the outcome of an accident/injury. The time taken from impact of Injury till the accessibility of medical treatment and nature of expertise available in that short window determines the outcome. In 1980’s Trunkey first described the trimodal distribution of deaths from trauma with regard to time which later became the basis of concept of “Golden hour”

Immediate Death ;  50 % of all deaths, not possible to save. Usually as result of massive head injury/ brain-stem injury/ cardiovascular event.

Early Death: 30% of all deaths, within first few hours, usually as result of injury to torso.

Late Death: 20% of all deaths, usually from organ failure and sepsis, influenced by inadequate early resuscitation and care & treatment of trauma victims within first few hours after injury.

The length of Blocks on x-axis represents the Time Window each particular injury gives before death or irrecoverable loss.

For instance if there is airway obstruction after an accident, the death will follow in few minutes as compare to injury to arm or leg. This variability in nature of outcome of different injuries helps to prioritize i.e which injuries demand immediate management and could be fatal if not responded. “Golden Hour” means the first hour after the accident in which life saving steps must be taken to reduce the risk of fatal consequences. This Concept of Golden Hour became the basis of ATLS;  Advance Trauma Life Support  (the details are beyond the scope  of this article).To simply it “these are standard Guidelines for doctors and health professionals set internationally for management of trauma. The Rescue services like 1122 are trained according to these guidelines.

 2- Safety Measures and their outcome on injuries:

This encompasses the most important and most neglected features in context of 3^rd world particularly Pakistan. And when we talk about Gilgit Baltistan, you will find blatant violations of these SOPs  which are somehow endorsed and enforced in urban cities to some extent. There is massive lack of awareness in general public, negligence and lack of will of law enforcing authorities in this regard. I won’t be emphasizing on this how ethical or civilized behavior it is to wear seat belts, helmets, and not indulge in rash driving/over-speeding, rather I would put it for readers as how gravely IMPORTANT these factors are in an RTA.

• Speed is most critical factor, a 10% increase in speed of impact translates into a 40% rise the case fatality for both restrained ( wearing seat belt) or unrestrained passenger.
• Ejection from vehicle of unrestrained passenger is associated with significantly greater incidence of severe injuries
• Use of seat belt is thought to reduce the risk of death or serious injury for front seat occupants by approx 45%.
• Unrestrained back seat occupant can also cause greater risk of injury to front seat occupant as they move forward and hit the front seat occupants upon impact.
• When back seat occupants are restrained (use seat belts) the risk of death for the restrained front seat occupants is reduced by 80%.
• Airbags reduce the risk of fatality by approx 30% but it must be noted that airbag can itself cause particular type of fatal injuries to risk group ( infants, children & older people)
• In Order to reduce Airbag induced injuries

1. Children younger than 12 years should be properly restrained in back seat.
2. Infants ( age less than 1 year) should never ride in front seat of vehicle fitted with passenger side airbags
3. All occupants must wear seat belts and seat should be moved as far back as possible from steering wheel and dashboard.

Motorcyclists facing RTA have 35 times greater death rate than that of cars.

• Helmets reduce the risk of fatal head injuries by 1/3^rd and facial injuries by 2/3^rd.
• Fractures of lower limbs are most common occurring in 40% of motorcyclists hospitalized for non-fatal injuries
• Children aged 5-14 yrs must never ride a motorcycle. Head injuries in this age group while riding motorcycle accounts for 75% of the death,
• Helmets reduce the risk of brain injury for motorcyclist/bicyclist by nearly 90%.

B-Reality Check of Existing Situation in GB.

You would now be having Goosebumps that the most killing factor in case of RTA is delayed treatment due to several reasons.A realistic analysis of current situation shows us that how much we lack in timely given Post Trauma treatment and on the other hand how brutally we are exposed to immense danger due to our own ignorance about safety measures. Even though today by the Blessings of “political baiting’ we have 11 districts which means theoretically we have 11 DHQs  but practically speaking only 3 of them have got required specialists & facility of emergency surgeries. Our political governments are so productive in fact ’reproductive’ that they give “birth” to more districts in each elections. A hospital doesn’t become a Cardiac Hospital just because an MNA placed a board & inauguration slab outside the same building, it has got certain pre-requisites to gain that status. Same is true for DHQ’s & THQ’s .Take district hunza for instance ‘the nearest referral  hospital with facility of surgeons to conduct emergency surgeries is DHQ Gilgit, Now imagine an hypothetical RTA near Attabad lake , the time spent on taking the victims ( if they are luckily on road and haven’t fall off from road) to nearest Health facility will be minimum 30 mins , by the time initial treatment which will be just passing a IV line, giving I.v fluids and pain killers , baseline x-ray and referral to DHQ Gilgit will take another 30 minutes, and then it will take further 2 and half hour to reach Gilgit, and if we take everything ideally , the time taken to call a surgeon and anesthetist would take another 30 mins, and by the time patient will be in operation theater the total time since the injury would be (30+30+150+30 =  240 mins  i.e  4 hours. There you see the “Golden Hour” management protocols going down the drain. Please note that this is extremely idealistic case scenario with maximum possible swiftness, in reality it takes more than 4 hours to send a patient of head injury to specialist care after the injury.

 So next time if any of your friend/relative feels like playing “fast and furious” on road remember these horrible realities and also remind him/her of these. To Summarize it “We only stand 20% chance of survival by medical intervention in case of trauma’ considering existing Emergency services and health facilities in case of any accident”.

Our reckless attitudes & its consequences;

Putting all these pieces together one can easily construct that how dangerously we are exposed to mortality & morbidity in case of any RTA. In addition to this horrible objectivity there is gross defect in our attitudes as well.

• lack of awareness about safety protocols and proper training to cope such situations.
• 80 % drivers on road wouldn’t even know that SOLID LINE on curves means DO NOT ATTEMPT OVER TAKE.  The 14 Km long tunnel also contains SOLID LINE just to be violated by everyone over speeding and overtakes.
• People drive with speed of 100 to 120 km /hr speed on KKH where speed limit will be 50 to 70 km/hr.
• Recall one person that you know in your circle who wears seat belt and asks others in the car as well.
• Recall one moment when you wore seat belt while driving in GB 90% of us would go blank on these questions.
• Violation of speed limits in dangerous areas is our normal routine.

 In my distant memory i have never heard of anyone getting medal by government or any other organization for reaching 30 minutes earlier but still every now and then I see people boasting their achievements of travelling a distance quicker then the normal time. One must ask himself what is the point of putting his life and lives of others at risk? Doesn’t this thought float in our minds for just a second that what if our over speeding leads us crashing into turbulent waves of mighty Indus with no bodies found for weeks and months? Do our loved ones deserve the additional agony and pain of “infinite wait” just to find a totally mutilated body after weeks?

We must realize and vow  to rectify these horrible tendencies we have. We must commit to ourselves that we will not ignore violation of safety rules if we see them and discourage such attitudes of our friends, siblings and relatives forcefully.

 What Needs to be done?

There is still lot to talk about this topic, and I don’t intend to just write a onetime article out of heat of emotion and forget it. Rather I am looking forward to start a proper  campaign, community mobilization and youth involvement to rectify the modifiable elements regarding RTA’s. More over I also think that it will fruitful if the health professional who are trained in  First Aid and ATLS would spend some time with rest of community to give basic training about “DO’s” and “DON’Ts” after any accident. There is role of government authorities in this regard as well to enforce Road traffic laws, stop and seal unregistered RENT A CAR services , keep a check on how much a driver has been utilized by particular agency in greed of more money. This can be easily done by making a LOG BOOK mandatory for such service providers so that if someone hires a car he/she would see how recently the driver has traveled and has he got enough time to take proper sleep ?

Most of us have  lost our loved ones, friends and relatives , one way or the other in these Road traffic Accidents.. I lost a very dear cousin in 2005 just because the driver got busy with adjusting the music system while driving and the jeep fell off from road. There are certain unavoidable factors which can’t be controlled like car hit by a Rock falling or Landslide. But we must collective make sure that no more lives are lost just because the driver was sleepy or no-one in the car had bothered to look at speedometer.

Dr. Atif is working as Medical Officer at the Civil Hospital Gulmit, Hunza.