On 25 April 2015 Nepal witnessed a huge earthquake of 7.8 magnitude claiming over 8000 lives and injuring more than 23,000[1].Those injured incurred either crush injuries, fractures or head and spinal cord trauma. WHO estimates,over 400 people have sustained spinal cord injuries owing to earthquake.[2]. They have become either paralyzed or developed weakness of limbs (paraparesis) extending from neck downward (quadriparesis) or in lower limbs (paraparesis) with bladder and bowel dysfunction. While many sustained primary injuries due to earthquake, many others sustained secondary injuries due to improper transportation of these patients to health facilities. Much of the reachable health facilities were damaged by earthquake and thus patients needing immediate spinal support were further deteriorated by this situation. In addition, majority of the health care providers involved in the search ,rescue and the evacuation were unaware of the concept of correct immobilization, log roll and transport technique. The use of the spinal board was hardly seen. This resulted in the neurological and vertebral damage further worsening to complete SCI(Spinal Cord Injuries). Spinal cord injury has a devastating effect in a person's life ranging from psychosocial impact to the different grades of disability. The challenges posed by spinal cord injuries vary in wide spectrum, particularly treatment of which demands clinician's technical expertise and advanced surgical facilities. Even in an advanced technical facility, treatment requires a concentrated effort and dedication of both the clinicians and the patients. With the good medical, nursing and physiotherapy most of the cases can be revived back to the normal. In Nepal, the only rehabilitation center, situated in Kavre district has received 150 patients with spinal injuries during the period of April to August 2015.There might have been several other cases of spinal cord injuries which might have been undocumented. Many undocumented cases might have been either unable to reach health center particularly, spinal cord- treating centres or might have given up hopes. This suggests the need of spinal injury treatment centres and inadequacy of current level of health facilities. Incomplete quadriplegia has good recovery while complete have bad prognosis. In Saga Spinal cord injury treatment center, among the treated cases, no death has been reported so far, however, the complications like Pressure sore has been reported in 16 patients. Impairment of autonomous dysfunction such as Urinary Treatment Centre has been reported in 50 patients and DVT (Deep Venous Thrombosis) in 6 patients. Out of the total 150 cases managed in this spinal cord treatment center, 50% underwent surgery for unstable fracture of spine while remaining were managed conservatively. In Nepal there are 20 spinal surgeons, 12 physiotherapists and 6 occupational therapists. These professionals are overburdened by current level of work. This necessitates the immediate need of further technical human resources.

References: 1. Nepal, G.o., Post Disaster Needs Assessment. 2015: Nepal. 2. WHO, WHO mobilizes funds for long-term spinal cord treatment after Nepal earthquake. 2015: Nepal.

Conflict of Interest:

None declared

A survey of jail inmates done by J P May, D Hemenway, and A Hall indicated that, among those who admitted to having been shot, 91% reported having gone to the hospital for treatment. This comment explains why this finding cannot be taken seriously.

Put yourself in the position of a jail inmate who was part of this survey. Most jail inmates are awaiting trial. They are the most legally vulnerable of all criminals - unlike uncaught criminals they are subject to legal punishment, yet unlike prison inmates, the punishment they will receive is still to be determined - the hammer has not yet come down. This is a set of criminals who are understandably obsessed with not looking any more criminal to the authorities than they already appear. How is this relevant to the jail survey conducted by May et al.? Suppose you were a jail inmate who had been shot, but did not seek medical treatment because you were shot while committing a crime, and knew that if did go to the hospital, police would interrogate you as to how you got shot and possibly connect you to the crime.

When such a jail inmate was asked whether they had ever been shot, either of 2 things would happen. The inmate would either accurately answer "yes" or would falsely deny having been shot, for the same reason that they did not seek hospital treatment - they did not want to be connected to the crime they were committing when they were shot. These inmates would not be asked the follow-up question "Did you go to the hospital for treatment of that wound?" They would simply be excluded from further analysis, and therefore would not go into the computation of the percent of the 307 gunshot-wounded inmates who had sought hospital care. Instead, they would erroneously be placed in the set of 1,816 inmates who did not report being shot. This is what is known to researchers as a "censored sample" - the inmates who had been shot while committing a crime and who did not seek hospital treatment would largely be "censored out" of the sample, leaving mostly inmates who been shot in less incriminating circumstances. It is scarcely surprising that many of these 307 inmates had sought medical treatment - those who were relatively "innocent victims" had no reason not to go to the hospital. This sample, however, can tell us nothing about the share of all criminals who are shot who received hospital treatment, and certainly can tell us nothing about the share of those shot by their victims while attempting a crime who received hospital treatment.

Now consider those who accurately reported having been shot, among those who had been shot by their victim while attempting to victimize them, and who consequently did not go to the hospital. These inmates may have been willing to report that they had been shot because they did not anticipate the surveyors asking any follow-up questions, such as the one concerning medical treatment. They were then asked the question as to whether they went to the hospital to get treated. At that point, an inmate of this sort could either accurately answer "no" or lie and answer "yes." How is such an inmate likely to perceive a truthful "no" answer? There is no sensible legitimate reason why an innocent victim of a gunshot wound would not seek professional medical treatment - being shot is a very serious injury, and the medically sensible step is to seek professional treatment of the injury. Only a person with something to hide from the police in connection with that wounding would avoid going to the hospital. The inmate knows this, and knows that the surveyors know it as well. So how likely is it that this inmate, in these legally vulnerable circumstances, would honestly answer "no"? Doing so would be tantamount to confessing to yet another crime that the authorities did not yet know about. Thus, there would be a powerful motivation to falsely answer "Yes," and no strong motivation to accurately answer "No," beyond the inmate's commitment to the general moral norm that one should not lie - a commitment that is likely to be lower in a sample of jail inmates than in the population as a whole.

In sum, (1) the subsample of jail inmates who had admitted having been shot is likely to have excluded most of those who had avoided hospital treatment because they were committing a crime when they were shot, and (2) among those who admitted being shot, few inmates were foolish enough to admit they had not sought medical treatment. Consequently, the claim that 90% of the inmates who had been shot had gone to the hospital cannot be given much credence.

The implicit underlying assumption of the researchers was that one could expect truthful answers from jail inmates who had powerful reasons to not be truthful. To be sure, those who had been shot as innocent victims could afford to seek hospital treatment and could be truthful about doing so when surveyed. These inmates probably account for most of the 316 inmates who reported seeking treatment. In contrast, it is extremely unrealistic to expect truthful answer from those who were shot by their victims while committing crimes that the authorities either did not know about, or did not know the inmate had committed. Inmates have no reason to conceal crimes that the authorities already know about, and prior research shows that they are indeed willing to self-report these offenses in surveys. Crimes for which the offender was never arrested are another matter entirely.

Conflict of Interest:

None declared