Dr. Andrés Rubiano is fostering a new consciousness and system for integral trauma care in Colombia. By converting the roles of hospitals, emergency medical agencies, and public sector institutions into coordinated and proactive responders to the dramatic problem of traumatic injury.
The New Idea
150,000 Colombian citizens a year die unnecessarily from severe traumatic injuries sustained from landmines, guerrilla and paramilitary warfare, homicide, and vehicular accidents. Andrés is constructing an integral primary care network for victims of trauma, many of whose lives are lost simply due to an inadequate and uncoordinated hospital and public health system. Andrés formed Foundation for the Medical and Technical Education and Investigation into Emergencies and Disasters (Meditech), as a citizen organization (CO) to train key actors in the best and proven scientific and educational techniques in trauma treatment and care and adapts it to a context that has never before experienced such a holistic program. Andrés is building awareness and expertise among the medical, emergency response and public health fields to stimulate them into supporting improved trauma care all around the country.
Andrés understands that integral care requires constructing a novel infrastructure of institutions and actors all committed to emergency medicine. With his education as a doctor specializing in trauma and his alliance-building capability, he brings together hospitals, medical schools, emergency response agencies and public health agencies to coordinate their training and planning to receive, process, and attend to victims of trauma. He also had the insight to incorporate other agencies not directly responsible for medical attention, such as law enforcement, but which have close interactions with trauma victims. By educating and transforming the roles of existing actors, Andrés has formed a powerful network that works in synch to provide high-quality care.
In addition to training key actors in their new and integrated roles in trauma care, Andrés is building toward systemic change, which must include changing government policy and regulations in the role of hospitals and the way that they carry out emergency care. By integrating Meditech’s model into institutional practices and agency policy, he foresees cultivating an environment that will facilitate the growth and maintenance of his integrated trauma networks. By helping to create the professional study of emergency crisis management and many different hospitals around Colombia inviting Meditech to train them in this innovative and effective approach to trauma, Andrés has found himself at a watershed moment in knitting together a national system of integral trauma care.
In a country where death from traumatic injuries leads as the number one cause of death, Colombia has nonetheless overlooked the problem. In addition to car accident deaths, which every country suffers, Colombia has two additional problems. First, there has been an explosion of motor bikes in every city, as a cheaper taxi and delivery service; secondly, Colombia still suffers high homicide rates after its decades of fierce conflict among drug cartels and right-and left-wing guerrillas, and from land mines still buried throughout the country. With a homicide rate fluctuating between 35 and 70 per 100,000 residents, a tragically high figure, and deaths from motorcycle accidents close to 40 percent of all vehicular accidents (compared to a regional average of 12 percent), the country should direct its resources and efforts to treating and preventing traumatic injury. Yet governments in Latin America have in recent years invested 10 to 12 times more in resources to prevent and manage infectious diseases, which comparatively are responsible for far fewer deaths in the region. Like its neighbors, Colombia lacks any coordinated policy; let alone any attention, to address its high mortality rate attributable to trauma. In fact, the government does not keep detailed figures on traumatic injury, rendering many attempts to create a policy impossible.
Deaths from trauma can be prevented if proper and speedy emergency response is taken. Andrés suggests that the mortality rate could decrease from 50 percent to 25 to 30 percent in Colombia with the right integral care. With 300,000 victims per year of severe trauma, more than 60,000 needless deaths could be prevented. In Colombia, victims from traumatic injuries are rarely considered until they reach the hospital door, often already dead or near death. Patients arrive delivered by taxis, police cars, fire trucks, or family or friends, all forms of transport that lack the rapid medical attention that emergency medical technicians could provide in an ambulance. Shockingly, until very recently in many places ambulances did not even exist to transport injured individuals to hospitals—a tragic fact that undoubtedly added to thousands of needless deaths during the country’s bloody civil conflict in the 1980s and 1990s. Once the victims reach the hospitals, they are poorly triaged and are shuffled around the hospital, where the medical personnel tend to undervalue or disdain the field of emergency medicine. The most inexperienced doctors and nurses must treat the patients, who as a result, often die in surgery by not receiving the specialized care they need.
On an institutional level, the hospital network in Colombia is not prepared to handle a coordinated system to receive and treat patients suffering from trauma. Three levels of hospitals comprise a hierarchal system that can attend to increasingly more complex needs while managing and administering the hospitals at a lower level. Level 1 hospitals, the most prevalent, are poorly suited to treating trauma, and are often located in rural areas without rapid access to Levels 2 and 3. Meanwhile, the few level 3 teaching hospitals located in cities are the only institutions outfitted with any semblance of trauma treatment. Yet as the Level 1 hospitals have the most expansive presence, they should be equipped with the best teams and technology to care for traumatic injuries.
Andrés created Meditech to stitch together a web of hospitals, medical students, emergency treatment providers, and public institutions that would offer high-quality and integral trauma care. He started in Neiva, a small city in the southern region of Colombia that lacked any trauma treatment and whose teaching hospital is one of the twenty level three facilities in Colombia. Since Meditech functions mainly as a catalyst to connect different actors with a train-the-trainer approach, it harbors only a small project coordination and administrative staff and a changing cohort of medical interns interested in learning about trauma care. Andrés receives the financial support mainly of foreign scientific associations and international organizations such as the World Health Organization (WHO). He does not accept government funding to avoid compromising Meditech’s ability to influence public hospital administrations.
Building awareness of the necessity of integral trauma care among the public health and hospital sectors is a fundamental first step for Andrés. In the Neiva teaching hospital he received a grant to put together a database on the incidence of trauma and associated mortality statistics. Just gathering these records is a success for Meditech; to underscore the problem of poor trauma care and to produce solutions. They also implemented the first free online web registry to generate real statistics about the quality of medical attention to trauma cases; no matter the sophistication of the medical clinic or hospital.
Equipped with this data, Meditech identifies COs, medical associations, medical schools, and emergency response institutions and offers them in-depth training on trauma care, using scientifically proven and professional methods. Andrés’ instruction incorporates practices and techniques in trauma care from countries with high-quality care but adapted to the Colombian context and emphasizes evaluating existing healthcare practices. This education integrates people with varying levels of expertise and understanding on trauma care (Andrés says that many of the most advanced clinicians and surgeons still lack a basic grasp of emergency medicine). He attributes this to a failure among medical schools to teach the subject. For this reason, Andrés is also designing a graduate degree in emergency medical systems that will formalize and institutionalize the training models that Meditech has already produced. He also actively involves medical students and medical interns in the education and practice of trauma care.
With a more educated base of doctors and responders, Andrés seeks to influence the hospital administration to include trauma care among its disciplines supported by the institution. He shows how the hospitals can organize their personnel, systems, and logistics to better receive trauma patients and triage them quickly and efficiently to the care they need. The hospitals begin to collaborate more concretely with the emergency-responders and rescue crew that bring the patients to the facility, which guarantees a faster response. Andrés also helps the hospital administrators to reorient and reprioritize the structure of the regional hospital system. He sees that the top Level 3 hospitals, like the hospital in Neiva, can train and spread the Meditech model among its subsidiary hospitals in the field. Rather than the top hospitals always receiving the patients that Levels 2 and 1 hospitals cannot treat, Andrés reverses the order of primary care. Medical student’s training at Level 3 hospitals can work at Level 1 hospitals to practice their techniques in trauma medicine while equipping the local medical personnel with the same skills. Not only does this exponentially expand the coverage of trauma care, it enables Level 3 hospitals to act more in an oversight role and dedicate their efforts and daily tasks to more complex surgical procedures.
Meditech has also identified a number of other agencies and institutions responsible for taking care of and treating trauma victims. Andrés has partnered with the Red Cross, long the only organization that provided any emergency delivery but often with a more informal, less professional approach. Having learned the Meditech procedures, Red Cross officials facilitate more integrated plans with the hospitals to deliver patients. Also, Andrés has involved different law enforcement agencies in his training. In a country where trauma is closely associated with violence and crime, police are often the first to encounter traumatic injuries, but they often lack the knowledge to provide basic treatment or mechanisms to ensure a safe transport to hospitals. Now Meditech is training police agencies, including the National Police Force, responsible for taking care of victims of nation-wide armed conflict. This agency, plus other search-and-rescue crews from the military that Meditech has partnered with, has been especially critical in expanding the integral model into remote rural areas of the country. So far, Meditech has trained 5,000 diverse professionals in Colombia, other countries in Latin America and the U.S.
Given their obvious central role in treating trauma victims, hospitals are the most crucial institutions for Meditech to influence. Thus, Andrés has added a policy focus into his work—not just among hospital administrations—but also in the greater public health sphere. He is carefully cultivating allies and champions among directors of hospitals to advocate for integral trauma care among their facilities and networks. While remaining wary of frequent corruption among the hospitals and the government, Andrés also seeks to reach lawmakers and agency heads that will be receptive to his cause and implement regulations enabling networks of trauma care providers. Andrés says that this work beyond the technical level is essential to amplify the impact of Meditech around the country. Hospital administrators who have seen the results are now coming to Meditech to request its assistance in training and forging comprehensive networks in their communities. By connecting these hospitals with other previous recipients of Meditech’s work, Andrés is also building cross-hospital relationships that can bypass Meditech. With such a critical mass, he will be able to advocate more persuasively for comprehensive policy change.
After his father’s death when he was just one-year-old, Andrés’ mother raised his family alone in humble conditions in Neiva. During high school, they moved to Cali, where they could be closer to her family. Experiencing his formative years there, Andrés witnessed the violent turmoil that ravaged Cali from 1991 through 1998. As a medical student, he volunteered in his free time with the rudimentary network of ambulances, and attended to trauma victims at the site of the incident. Andrés saw the failure of the broken emergency response system to save the lives of people from needless deaths, an experience that marked him deeply as his career progressed. After graduating from medical school, he completed a year of service in his hometown of Neiva. In a small city where neither an ambulance network nor hospital expertise in trauma care existed, Andrés became the first to draw attention to this need while training medical technicians in basic emergency medicine.
Andrés specialized in the field of neurosurgery with a focus on neurotrauma. He was fortunate to study at some of the most prominent neurotrauma hospitals in the U.S., spending time at the University of Pittsburgh and Virginia Commonwealth University and interning at their teaching hospitals. This access to leading surgeons and researchers helped Andrés develop new techniques to treat trauma. He also came to understand the importance of networks beyond hospital institutions, to integrate emergency response, law enforcement, and medical care for the safe and rapid care of trauma victims.
Turning down positions in the U.S., Andrés returned to Colombia to continue his neurosurgery practice. As a resident at the top private hospital in Bogota, he sought to launch a neurotrauma division among the hospital staff. Trying to convince the reluctant hospital administration of the importance and grave need for such an initiative, Andrés authored the first book in Spanish on the subject and published it around Latin America. After completing his residency, Andrés moved back to Neiva. With his contacts in the civil defense field he designed the strategy for Meditech and pieced together the web of actors and institutions that would be the first emergency response network. With a successful program and with hospitals in other parts of Colombia requesting Meditech, Andrés is ready to walk away from his career as a neurosurgeon and dedicate himself to constructing a comprehensive system of trauma care around his country.