Mads Gilbert

Resuscitation from accidental hypothermia of 13·7°C with circulatory arrest

Summary Summary In a victim of very deep accidental hypothermia, 9 h of resuscitation and stabilisation led to good physical and mental recovery. This potential outcome should be borne in mind for all such victims.

Rural prehospital trauma systems improve trauma outcome in low-income countries : A prospective study from North Iraq and Cambodia

BACKGROUND A five-year prospective study was conducted in North Iraq and Cambodia to test a model for rural prehospital trauma systems in low-income countries. RESULTS From 1997 to 2001, 135 local paramedics and 5,200 lay First Responders were trained to provide in-field trauma care. The study population comprised 1,061 trauma victims with mean evacuation time 5.7 hours. The trauma mortality rate was reduced from pre-intervention level at 40% to 14.9% over the study period (95% CI for difference 17.2-33.0%). There was a reduction in trauma deaths from 23.9% in 1997 to 8.8% in 2001 (95% CI for difference 7.8-22.4%), and a corresponding significant improvement of treatment effect by year. The rate of infectious complications remained at 21.5 percent throughout the study period. CONCLUSION Low-cost rural trauma systems have a significant impact on trauma mortality in low-income countries.

Respiratory rate as a prehospital triage tool in rural trauma.

BACKGROUND Where trauma systems do not exist, such as in low-income countries, the aim of prehospital triage is identification of trauma victims with high priority for forward resuscitation. The present pilot study explored the accuracy of simple prehospital triage tools in the hands of nongraduate trauma care providers in the minefields of North Iraq and Cambodia. METHODS Prehospital prediction of trauma death and major trauma victims (Injury Severity Score > 15) was studied in 737 adult patients with penetrating injuries and long evacuation times (mean, 6.1 hours). RESULTS Both the respiratory rate and the full Physiologic Severity Score predicted trauma death with high accuracy (area under the curve for receiver-operating characteristic plots at 0.9) and significantly better than other physiologic indicators. The accuracy in major trauma victim identification was moderate for all physiologic indicators (area under the receiver-operating characteristic curve, 0.7-0.8). CONCLUSION Respiratory rate > 25 breaths/min may be a useful triage tool for nongraduate trauma care providers where the scene is chaotic and evacuations long. Further studies on larger cohorts are necessary to validate the results.

Preventing post-injury hypothermia during prolonged prehospital evacuation.

INTRODUCTION Post-injury hypothermia is a risk predictor in trauma patients whose physiology is deranged. The aim of the present study was to examine the effect of simple, in-field, hypothermia prevention to victims of penetrating trauma during long prehospital evacuations. METHODS A total of 170 consecutively injured landmine victims were included in a prospective, clinical study in Northern Iraq and Cambodia. Thirty patients were provided with systematic prehospital hypothermia prevention, and for 140 patients, no preventive measures were provided. RESULTS The mean value for the time from injury to hospital admission was 6.6 hours (range: 0.2-72). The incidence of hypothermia (oral temperature < 36 degrees C) before prevention/rewarming was 21% (95% confidence interval: 15% to 28%). The Prevention Group had a statistically significant lower rate of hypothermia on hospital admission compared to the control group (95% confidence interval for difference: 6% to 24%). CONCLUSION Simple, preventive, in-field measures help to prevent hypothermia during protracted evacuation, and should be part of the trauma care protocol in rural rescue systems.

Challenges of major incident management when excess resources are allocated: experiences from a mass casualty incident after roof collapse of a military command center.

During a military exercise in northern Norway in March 2000, the snow-laden roof of a command center collapsed with 76 persons inside. Twenty-five persons were entrapped and/or buried under snow masses. There were three deaths. Seven patients had serious injuries, three had moderate injuries, and 16 had minor injuries. A military Convalescence Camp that had been set up in a Sports Hall 125 meters from the scene was reorganized as a causality clearing station. Officers from the Convalescence Camp initially organized search and rescue. In all, 417 persons took part in the rescue work with 36 ambulances, 17 helicopters, three ambulance airplanes and one transport plane available. Two ambulances, five helicopters and one transport aircraft were used. Four patients were evacuated to a civilian hospital and six to a field hospital. The stretcher and treatment teams initially could have been more effectively organized. As resources were ample, this was a mass casualty, not a disaster. Firm incident command prevented the influx of excess resources.

Bystander first aid in trauma - prevalence and quality: a prospective observational study

Bystander first aid and basic life support can likely improve victim survival in trauma. In contrast to bystander first aid and out‐of‐hospital cardiac arrest, little is known about the role of bystanders in trauma response. Our aim was to determine how frequently first aid is given to trauma victims by bystanders, the quality of this aid, the professional background of first‐aid providers, and whether previous first‐aid training affects aid quality.

Bridging the gap: building local resilience and competencies in remote communities.

This keynote address will focus on the potential to reduce the increasing gap between rich and poor countries. This critical gap only can be bridged if we systematically replace the expensive and reactive international disaster post-hoc operations by systematic, long-term, proactive efforts to increase the local capacity to master everyday accidents and emergencies as well as empower the local preparedness for major events such as natural and technological events. If we really wish to strengthen local preparedness and competencies in remote communities in lowand middle-income countries (LMIC, “the South”), we must systematically share knowledge and skills through scientifically proven training programs aimed at such impoverished, still densely populated regions in the South. Such local training represents a sustainable, long-term action to build emergency medical capacity into the local population and the health workers, as opposed to only relying on expensive foreign relief that arrive too late, is cost ineffective, and most often responds to spectacular disasters. Building local competence also strengthens local resilience (Table 1).

Nurses and social care workers in emergency teams in Norway

BACKGROUND The Norwegian counties Troms and Finnmark are dominated by large areas with widespread habitation and rather long response times for ambulances and doctors. We wished to investigate the extent to which the municipal preparedness in these counties use employees from the municipal nursing and social care services and if these are part of local emergency teams. MATERIAL AND METHODS In the autumn of 2008, we sent a questionnaire to the district medical officers and the leaders for municipal nursing and social care services in all 44 municipalities in Troms and Finnmark. The answers were analyzed manually. RESULTS 41 municipalities responded. In 34 of these the municipal nurses and social care workers practice emergency medicine procedures. The content in these training sessions is much more comprehensive than that in a typical first aid course. In three of four municipalities ambulance personnel do not participate in this training. In 31 municipalities the inhabitants contact nurses and social care workers directly if they are acutely ill. In only 10 of the municipalities the nurses and social care workers are organized in local teams including a doctor and an ambulance. INTERPRETATION In the districts, nursing and social care services are a resource in an emergency medicine context. The potential within these professions can be exploited better and be an important supplement in emergencies. In emergencies, cooperation across disciplines requires a clear organizational and economical structure, local basis and leadership.