Prevalence and determinants of posttraumatic stress disorder and depression among survivors of motor vehicle accidents from a hilly Indian state.

BACKGROUND: Motor vehicle accidents (MVAs) are the leading cause of death and have also been proven debilitating for their survivors. In India, with poor road infrastructure and low maintenance, MVAs are quite apparent. With a significant focus of treatment on physical health, psychological consequences linked to these traumas are often neglected. AIM: The aim of this study was to estimate the prevalence of posttraumatic stress disorder and depression, as well as the determinants of these disorders among survivors of MVAs.
MATERIALS AND METHODS: An institution-based, cross-sectional descriptive study was conducted among 250 survivors of MVA visiting a tertiary care center in Uttarakhand (India) during December 2019, recruited using total enumerative sampling. Data were collected with standardized and validated tools that consisted of sociodemographic information, Posttraumatic Stress Disorder Checklist 5, and Zung Self-Rating Depression Scale. Data were analyzed using SPSS version 23, including descriptive (frequency, percentage, mean, and mean percentage) and inferential statistics (Mann-Whitney, Kruskal-Wallis, and binary logistic regression).
RESULTS: The prevalence of posttraumatic stress disorder (PTSD) was found to be 32.4%, and mild and moderate depressions were present among 14.4% and 6.4% of the study population, respectively. Witnessing death (odds ratio [OR] = 5.52; 95% confidence interval [CI] = 0.92-3.06), loss of valuables (OR = 2.62; 95% CI = 0.78-9.04), self-blame (OR = 6.06; 95% CI = 1.15-31.91), and perceived death threat (OR = 9.98; 95% CI = 5.89-46.85) acted as determinants in the occurrence of PTSD and depression.
CONCLUSION: A considerably large proportion of the population suffered from psychiatric disorders following the trauma. These must be addressed with an urgent development of multidisciplinary teams incorporating mental health services across all hospitals' trauma units. Copyright:

INTRODUCTION

“Every year, the lives of approximately 1.35 million people are cut short due to a road traffic crash worldwide. Motor vehicle accidents (MVAs) are now the primary cause of death, mainly among people aged 15–29 years. Furthermore, between 20 and 50 million more people suffer nonfatal injuries, with many incurring a disability as a result of their injury.”[1] In India, the morbidity, disability, and mortality are high, with estimated road traffic death rate substantially increasing from 16.6% in 2013 to 22.6% in 2016.[2] The rapidity of occurrence has reached one vehicular accident every 3 min and one death every 10 min.[3] The consequences and costs of these losses are significant.

Road traffic accidents (RTAs) are a rapidly growing burden, especially in developing countries, posing a high economic burden on low- and middle-income countries.[4] Despite the burden, MVAs remain a largely overlooked public health problem, especially in such countries.[5] Often, the treatment of MVAs addresses only physical concerns, while the psychological aspects are ignored. A meta-analysis found that 1489 out of 6804 RTA survivors had posttraumatic stress disorder (PTSD).[6]

PTSD is characterized by re-experiencing the traumatic event in the form of vivid dreams, disturbing memories, flashbacks, or nightmares, which are accompanied by strong or overwhelming emotions, particularly fear or horror, and intense physical sensations. Such persistent heightened current threat causes significant impairment in personal, family, social, educational, occupational, or other important areas of functioning as per the International Classification of Diseases 11thversion.[7]

About 8 million people have PTSD in a given year, and out of the total population who experience traumatic events, 20% of people will develop PTSD.[8] While considering the Indian perspective, the prevalence varies from a lesser percentage to as high as 70%, which can be due to methodological differences, methods of sampling, or case detection.[9] A common psychiatric illness comorbid with PTSD is depression.[10] A high percentage of the PTSD group who recently faced a MVA also met the criteria of major depressive disorder.[11] A prior history of depression is a significant risk factor of developing PTSD as there are more chances, approximately 3–5 times more, to have depression among people with PTSD than their counterparts. In the recent past, depression has become a common mental disorder, with statistics reaching an alarming rate of 1 in 10 people suffering from depressive disorder every year.[8] People with depression commonly present with complaints of persistent sad mood, loss of interest in previously pleasurable activities, decreased energy, guilt or low self-esteem, disturbed biological functioning, and poor concentration. According to the WHO, globally, more than 300 million people of all ages suffer from depression.[12]

Studies of adult RTAs have shown similar results with higher psychological disturbances and distress among those who survived a severe trauma such as a RTA, among which PTSD and depressive disorders of moderate severity are most frequent.[13] The lifetime prevalence of depression in the general population is about 10%–20%; likewise, depression is one of the most prevalent disorders reported in persons involved in a MVA.[10] Depression does not occur in isolation; instead, it is accompanied by PTSD in 48.99% of posttrauma patients.[14]

About 85% of people who met with a traumatic event during their lifetime did not undergo any intervention to overcome the emotional stress caused by the trauma.[15] However, many people face immense difficulty adapting to circumstances that include psychological, social, physical, legal, and financial challenges.[16] Increasing vehicular mobility in developing countries, like India, necessitates further research to assess MVAs' psychological effects. In this context, the current study assessed the prevalence of and factors affecting PTSD and depression among survivors of MVAs visiting a tertiary care center.

MATERIALS AND METHODS

A cross-sectional descriptive study was conducted at All India Institute of Medical Sciences, Rishikesh, India, during December 2019 to estimate the prevalence of PTSD and depression, their correlation, and association with sociodemographic variables of the study population. Permission was obtained from the Institutional Ethics Committee (IEC) to carry out the study with Registration No. ECR/736/Inst/UK/2015/RR-18. Anonymity and confidentiality of information were maintained, and informed consent was obtained. Patients who had symptoms and fulfilled the diagnostic criteria for PTSD/depression were referred for consultation.

Sample size and sampling

As per the prevalence rate from previous studies,[17] the required sample size was estimated using the following formula n = Z2P (1 − P)/d2. The sample size was calculated, which came out to be 245 in number. Considering the attrition rate, 250 patients were recruited from different clinical departments of the selected tertiary care center, using a total enumerative sampling technique. After obtaining consent, patients who fulfilled the inclusion and exclusion criteria were included in the study.

Sampling criteria

Patients visiting various departments of the tertiary care center, aged between 19 and 65 years, literate (who can read and write with understanding in Hindi/English), and who survived MVA at least 1 month to 12 months before data collection were included in the study. Patients with a history of psychiatric illness, presence of head injury during an accident, presence of other significant medical/surgical comorbidities (factors which may increase the level of stress among survivors of MVA), and those under substance intoxication at the time of the interview were excluded from the study.

Questionnaire

Data were collected via an interviewer-administered questionnaire, which contained three main sections. These were the sociodemographic details (sociodemographic profile, accident profile, and clinical profile), the prevalence of PTSD, and depression among the study population.

Posttraumatic Stress Disorder Checklist (PCL-5) was used to assess PTSD (Weathers, Litz, et al., 2013). It is a 20-item self-report measure that corresponds to the DSM-5 diagnostic criteria for PTSD. Each item score ranges from 0 to 4 as not at all (0), a little bit (1), moderately (2), quite a bit (3), and extremely (4). The total score of the tool is 80 and obtained by summing the scores of the 20 items. A cutoff score of ≥33 was used for the provisional diagnosis of PTSD.

Zung Self-Rating Depression Scale (ZSRDS) (Zung, 1965) includes a total of 20 items that rate the four common characteristics of depression: the pervasive effect, the physiological equivalents, other disturbances, and psychomotor activities. Out of 20 items, 10 are positively worded, and 10 are negatively worded questions. Each item is scored on a scale of 1–4 (a little of the time, some of the time, a good part of the time). The score ranges from 20 to 80, and as per the score attained, the patients were categorized into normal (25–49), mildly depressed (50–59), moderately depressed (60–69), and severely depressed (70 and above).

The tools used for the present study were translated into the local language (Hindi) and were validated by the experts from the field of psychiatry, psychiatric social work, psychologists, and psychiatry nursing for its relevance and appropriateness. Content validity index for Hindi translated tool was calculated with a score of 0.80 and 0.84 for PCL-5 and ZSRDS, respectively. The translated tools were pretested and assessed for reliability using the split-half method. Tools have presented excellent psychometric properties with impressive validity and reliability scores. PCL-5 represented a reliability score of 0.75, whereas ZSRDS showed a score of 0.70.

Data analysis

Data were analyzed using Statistical Package for Social Sciences (SPSS 23.0) developed by International Businesses Machines Corporation (IBM), New York, USA. Sociodemographic, accident, and clinical characteristics were assessed using frequency distributions. PTSD and depression scores of the study population were nonnormally distributed, indicating a skewed distribution. Thus, nonparametric tests (Mann–Whitney U and Kruskal–Wallis) were used. Binary logistic regression analysis was conducted to determine the association between PTSD, depression scores, and sociodemographic characteristics. An adjusted odds ratio (OR) was calculated with a 95% confidence interval (CI) to determine the level of significance at P < 0.05.

RESULTS

Data were collected from a total of 250 study participants visiting the various departments of the tertiary care center. Almost half (42.4%) of the study population comprised those in the age range of 31–45 years. There was a clear preponderance (77.2%) of males among the study population. Most of them were married (78.8%) and belonged to upper lower socioeconomic status (58.4%). Accident characteristics, clinical characteristics, and their association with PTSD and depression severity scores are depicted in Tables 1 and 2.

Table 1

Association between accident profile and severity of scores of posttraumatic stress disorder and depression

Characteristics	Frequency (%)	PTSD severity score (PCL-5)			Depression severity score (ZSRDS)
		Median	IQR	P	Median	IQR	P
Accident group
Vehicle driver	141 (56.4)	20.00	23	0.50	26.00	26	0.04*
Pillion rider	69 (27.6)	20.00	21		20.00	16
Passenger	25 (10)	20.00	26		23.00	23
Pedestrian	15 (6)	20.00	17		28.00	17
Nature of accident
Collided with another vehicle	149 (59.6)	20.00	27	0.19	20.00	23	0.001*
Collided with a stationary object	42 (16.8)	20.00	18		20.00	14
Collided with a pedestrian	25 (10)	20.00	17		36.00	17
Fallen from height	25 (10)	32.00	26		36.00	22
Others	9 (4.2)	41.00	22		52.00	20
Number of vehicles involved
1	72 (28.8)	20.00	13	0.35	20.00	18	0.56
2	174 (69.6)	44.00	17		23.00	24
3	2 (0.8)	22.00	0		20.00	0
≥4	2 (0.8)	20.00	0		20.00	0
Type of vehicle involved
Two-wheeler	192 (76.8)	20.00	12	0.45	20.00	21	0.24
Three-wheeler	11 (4.4)	23.00	10		24.00	11
Four-wheeler	16 (6.4)	20.00	5		20.00	17
More than four-wheeler	31 (12.4)	20.00	26		20.00	30
Speed of the vehicle (km/h)
≤30	57 (22.9)	23.00	9	0.59	23.00	19	0.59
31-59	136 (54.4)	20.00	20		20.00	22
≥60	57 (22.8)	23.00	25		23.00	25
Use of seat belt/helmet by driver and pillion rider†
Yes	101 (40.4)	20.00	11	0.48	20.00	16	0.48
No	109 (43.6)	28.00	31		28.00	29
Witnessed death
Yes	23 (9.2)	48.00	24	0.55	48.00	32	0.55
No	227 (90.8)	20.00	12		20.00	18
Loss of valuables
Yes	43 (17.2)	44.00	24	0.94	26.68	35	0.94
No	207 (82.8)	20.00	17		26.39	17
Current litigation/compensation
Yes	17 (6.8)	48.00	30	0.14	48.00	35	0.14
No	233 (93.2)	20.00	18		20.00	20

*P value significant at≤0.05; †Total number of participants is 210. IQR Interquartile range; ZSRDS Zung Self-Rating Depression Scale; PCL-5 Posttraumatic Stress Disorder Checklist; PTSD Posttraumatic stress disorder

Table 2

Association between clinical profile and severity of scores of posttraumatic stress disorder and depression

Characteristics	Frequency (%)	PTSD severity score (PCL-5)			Depression severity score (ZSRDS)
		Median	IQR	P	Median	IQR	P
Nature of injury
Bruise	15 (6)	20.00	0	0.05*	20.00	0	0.18
Laceration	7 (2.8)	20.00	18		21.00	19
Fracture	175 (70)	21.00	27		25.00	25
Soft-tissue injury	50 (20)	21.00	18		27.00	27
Polytrauma	3 (1.2)	38.00	0		20.00	0
Substance use by the driver
Yes	29 (11.6)	50.00	41	0.001*	35.00	31	0.001*
No	112 (44.8)	20.00	11		23.00	22
Type of treatment
Medical	86 (34.4)	34.61	7	0.26	20.00	7	0.16
Surgical	10 (4)	50.30	26		45.00	12
Both medical and surgical	123 (49.2)	49.00	35		31.00	26
Others	31 (12.4)	39.80	24		25.00	21
Ability to recall the accident
Clear	181 (72.4)	20.00	9	0.40	20.00	11	0.62
Patchy	56 (22.4)	38.00	32		38.00	32
None	13 (5.2)	41.00	41		51.00	25
Blames self for accident
Yes	17 (6.8)	67.83	35	0.001*	26.00	31	0.02*
Partly	29 (11.6)	43.50	5		45.00	32
No	204 (81.6)	36.39	6		20.00	17
Death threat from the accident
Yes	76 (30.4)	41.54	18	0.05*	50.00	21	0.13
No	174 (69.6)	37.55	2		20.00	8
History of accident
Yes	14 (5.6)	26.00	30	0.54	33.00	28	0.72
No	236 (94.4)	20.00	21		20.00	22
Past history of disability
Yes	7 (2.8)	27.00	27	0.26	20.00	8	0.61
No	243 (97.2)	20.00	20		23.00	24

*P value significant at≤0.05. IQR Interquartile range; ZSRDS Zung Self-Rating Depression Scale; PTSD Posttraumatic stress disorder; PCL-5 Posttraumatic Stress Disorder Checklist

Prevalence of posttraumatic stress disorder and depression among survivors of motor vehicle accidents

PTSD was found to be prevalent among 32.4% of the survivors of a MVA, and depression was found to be prevalent among 20.8% of them; 14.4% were mildly depressive, and 6.4% were moderately depressive after the trauma.

Correlation between the prevalence of posttraumatic stress disorder and depression

A strong positive correlation was found between PTSD and depression score (r = 0.80; P = 0.00) [Table 3].

Table 3

Correlation between the prevalence of posttraumatic stress disorder and depression

Variables	r	P
PTSD	0.80*	0.001
Depression

*r Pearson’s correlation significant at the 0.01 level (two-tailed). PTSD Posttraumatic stress disorder

Association between posttraumatic stress disorder, depression, and sociodemographic characteristics

Sociodemographic, accident, and clinical profile with posttraumatic stress disorder and depression

Among sociodemographic characteristics, participants aged >45 years (P = 0.002) and who were just literate (P = 0.001) were found to be significantly associated with PTSD, whereas depression was more common among participants who lived in urban areas (P = 0.01). Considering the accident profile, those who drove the vehicle at a faster speed (P = 0.001), witnessed death (P = 0.03), and lost valuables (P = 0.02) were associated with PTSD. A different trend was observed with depression and its variables, where pillion rider and whose vehicle collided with stationary objects were associated with depression.

Moreover, clinical profile illustrated that participants who sustained fracture posttrauma (P = 0.05), used substance while driving (P = 0.001), blamed self for the accident (P = 0.001), and perceived death threat from the accident (P = 0.05) were found to be significantly associated with PTSD. Similarly, the participants' use of the substance and perceived death threat contributed to the prevalence of depression [Tables 1 and 2].

Binary logistic regression analysis of study variables

To explore how individual factors influence the prevalence of PTSD and depression, while controlling for the effects of other factors, binary logistic regression analysis was performed. Loss of valuables (OR = 2.62; 95% CI = 0.78–9.04), witnessing death (OR = 5.52; 95% CI = 0.92–3.06), and death threat (OR = 8.23; 95% CI = 4.93–48.40) were the significant predictors of PTSD [Table 3]. In context of depression [Table 4], accident group (OR = 0.48; 95% CI = 0.24–0.95), nature of accident (OR = 1.45; 95% CI = 1.09–1.92), self-blame (OR = 6.06; 95% CI = 1.15–31.91), and death threat (OR = 9.98; 95% CI = 5.89–46.85) were found to be the significant predictors of level of depression [Tables 4 and 5].

Table 4

Binary logistic regression of sociodemographic variables with level of posttraumatic stress disorder

Sociodemographic variables	P	Exp(B)	95% CI for Exp(B) (lower-upper)
Education
Below higher secondary	0.85	1.04	0.66-1.63
Higher secondary and above
Speed of the vehicle (km/h)
≤40	0.50	0.75	0.32-1.74
>40
Loss of valuables
Yes	0.01*	2.62	0.78-9.04
No
Nature of injury
Fracture	0.71	1.15	0.52-2.58
Others†
Witnessed death
Yes	0.05*	5.52	0.92-33.06
No
Use of substance by the driver
Yes	0.25	1.41	0.77-2.55
No
Self-blame
Yes	0.16	1.71	0.80-3.65
No
Threat of death
Yes	0.001*	8.23	4.93-48.40
No

*P value significant at ≤0.05; †Bruise, laceration, soft-tissue injury, and polytrauma. CI - Confidence interval

Table 5

Binary logistic regression of the sociodemographic variables with level of depression

Sociodemographic variables	P	Exp(B)	95% CI for Exp(B) (lower-upper)
Habitat
Rural	0.193	0.62	0.31-1.26
Urban
Accident group
Vehicle driver/pedestrian	0.03*	0.48	0.24-0.95
Pillion rider/passenger
Nature of accident
Fracture	0.01*	1.45	1.09-1.92
Others†
Use of substance by the driver
Yes	0.20	0.70	0.41-1.21
No
Witnessed death
Yes	0.10	1.86	0.87-3.99
No
Self-blame
Yes	0.03*	6.06	1.15-31.91
No
Threat of death
Yes	0.001*	9.98	5.89-46.85
No

*P value significant at ≤0.05; †Bruise, laceration, soft-tissue injury, and polytrauma. CI - Confidence interval

DISCUSSION

With the increased incidence of MVAs and advanced trauma services focusing on precise management of physical aspects, often psychological consequences remain untouched. These psychological traumas emerge out later with possibly even worse prognosis.

Findings related to the prevalence of posttraumatic stress disorder

PTSD is a common psychological disorder among MVA victims. The present study reported a high prevalence of PTSD (32.4%) among survivors of MVA visiting various departments of the tertiary care center. The possible reason for it could be inapt psychological care, lack of awareness about the importance of psychological health, and severity of the trauma. Prevalence of PTSD was consistent with the study conducted in Israel[18](32%) and Iran[19](30.49%).

However, the prevalence was lower compared to previous studies conducted in southern Nigeria,[10]41.3%; Ethiopia,[20]46.5%; and Portugal,[21]58.9%. This difference could be attributed, partially, to the exclusion of survivors with significant medical or surgical comorbidity in our study. Patients with severe injuries tend to negatively appraise the situation, which could have increased the prevalence of PTSD.

Prevalence of PTSD in the present study was lower than studies conducted in Ethiopia,[17]22.8%; southeastern Nigeria,[22]26.7%; Australia,[23]19.3%; southern Ethiopia,[24]15.4%; and Zurich,[25]4.7%. This varied prevalence of PTSD could be explained by different time points of PTSD assessment, different sample sizes, and cultural and socioeconomic status among the study population. A systematic review also confirmed the diverse prevalence extending from 6% to 45%, with probable cultural and socioeconomic factors influencing the PTSD following traumatic events.[26] Data from the National Survey of Adolescents-Replication reported a 7.4% prevalence of PTSD.[13] Furthermore, a PRISMA-compliant meta-analysis identified the pooled prevalence of PTSD to be 22.25%.[6]

Twenty percent of the participants developed PTSD following a motor vehicle crash in a study from India.[27] A high prevalence of psychiatric morbidity noted among the Indian population could be due to a lack of treatment and unavailability of mental health services. This can be worsened by logistical issues such as delay in reaching the health centers and topographical issues in hilly areas of India.[3] Hence, for the management of PTSD in the Indian population; development of coordinated triage, implementation of a screening the MVA survivors for PTSD and Depression in the emergency department and providing psychological counseling has been proposed.[28]

Findings related to the prevalence of depression

Several psychological disorders are prevalent globally, out of which lifetime prevalence of depressive disorders was found to be 5.25%.[29] One study showed an alarming prevalence of depression by up to 63% among MVA survivors.[10] The current study reports a prevalence of 20.8% for depression: mild depression (14.4%) and moderate depression (6.4%). This finding is similar to a study by Hassankiadeh et al. (2017)[19] at 19.89%. A much higher magnitude of depression has been found by Rebecca et al. (2018)[23] at 53.2%. A high prevalence of depression could be due to the use of self-report screening instruments, which tend to overestimate the psychological problems compared to clinical interviews conducted by trained mental health professionals. Among various mood disorders occurring in the aftermath of trauma, depression emerged out to be the commonest, highlighting the importance of early recognition and treatment.

Relationship between posttraumatic stress disorder and depression

In the present study, there is a significantly high positive correlation between PTSD and depression (r = 0.80). It has been commonly found that PTSD increases the risk of developing and further worsening depressive symptoms.[18] Similarly, while assessing the psychosocial and mental variables associated with PTSD in an Iranian study, depression proved to be an important factor in PTSD.[30] Furthermore, Blanchard et al. (1995)[11] revealed that PTSD and depression were prevalent among 39% and 53% of the population, respectively. People after trauma are perhaps vulnerable to depression; probable mediators could be an extended stay in the hospital leading to social distancing, constant or persistent pain due to injury or surgery, loss of loved ones involved in MVA, contributing to survivor guilt, and a lack of financial support.

Association between various sociodemographic factors with posttraumatic stress disorder and depression

Among the sociodemographic characteristics, age had a statistically significant association with PTSD; specifically, participants aged >45 years had more chances of developing PTSD. However, this finding differs from previous studies in which younger age had a significant association with PTSD.[31] A possible reason could be the preponderance of middle-aged and older population in the current study. Furthermore, education and habitat were found to be associated with PTSD (P = 0.00) and depression (P = 0.01), respectively, but logistic regression did not confirm these findings. Literature reported that there is a relationship between the level of education and PTSD and that the participants with high school education and who are not yet graduated develop PTSD more often.[626] In contrast, the current study depicts that participants with a postgraduate and above degree are more prone to develop PTSD. In terms of habitat, urban dwellers have more chances of developing depression.[11]

Although there was no association found between gender and occurrence of PTSD and depression, numerous studies have shown a significant association between both; female had a higher risk of developing PTSD and depression, possibly due to different ways of handling a stressor between genders and females experiencing more fear and helplessness in comparison to their male counterparts.[61017212227] Lack of association with gender could be due to fewer females involved in the study compared to their male counterparts. Considering the various accident-related and clinical characteristics, the present study found that factors such as witnessing death, loss of valuables, self-blame, and perceived death threats play a contributory role (2–8 fold higher risk) in PTSD. On the other hand, survivors who blamed themselves for MVAs were six times more likely to be depressed. The present study findings have well-established supportive pieces of evidence by systematic reviews[19212532] which display perceived death threat as a contributory factor in the development of PTSD.

Fekadu et al. (2019)[20] reported that those who witnessed death were more prone to develop PTSD similar to the current study finding (OR: 5.52; CI: 0.92–33.06). Seethalakshmi et al. (2006)[27] reported that pedestrians were more likely to develop psychiatric complications than drivers which concurs with our findings. Although previous researchers[192232] reported a relationship between occupation/work status with PTSD and depression, no such findings were observed in the present study. Loss of jobs with financial difficulties may have led to a negative appraisal of the situation.[192232]

Limitations

The study is limited due to a smaller sample of groups with nonprobability sampling techniques, which limits the generalizability of the findings outside the study settings. Other physical diseases/illness factors were not explored in the study, which may affect the psychopathology of MVA survivors. Recall bias can also affect the findings of this study.

CONCLUSION

Researchers conclude that there is a high prevalence of both PTSD and depression among survivors of MVAs; several factors possibly modulate these disorders and their persistence. An increasing trend in the number of accidents will likely add to the burden of these. Among various factors, perceived death threat, self-blame, and witnessing the accident had a remarkable association with these psychological disorders which raises a concern toward the psychological health of those who met with an accident, as it may lead to poor health outcomes. These imply a substantial need for identifying and managing the psychological effects of MVA trauma.

High prevalence is concerning and raises the need of promoting multidisciplinary health services in trauma units as well as at the community level to prevent the development of long-term mental health disability. Prompt identification of at-risk individuals by frontline health workers will ultimately lead to early interventions, facilitating quick recovery from MVA-related injuries. The study advocates for training health professionals in identifying psychological issues, providing counseling services and management of crisis across health settings especially in trauma units.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.