Torben Wisborg

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.

Leadership is the essential non-technical skill in the trauma team--results of a qualitative study.

BackgroundTrauma is the leading cause of death for young people in Norway. Studies indicate that several of these deaths are avoidable if the patient receives correct initial treatment. The trauma team is responsible for initial hospital treatment of traumatized patients, and team members have previously reported that non-technical skills as communication, leadership and cooperation are the major challenges. Better team function could improve patient outcome. The aim of this study was to obtain a deeper understanding of which non-technical skills are important to members of the trauma team during initial examination and treatment of trauma patients.MethodsTwelve semi-structured interviews were conducted at four different hospitals of various sizes and with different trauma load. At each hospital a nurse, an anaesthesiologist and a team leader (surgeon) were interviewed. The conversations were transcribed and analyzed using systematic text condensation according to the principles of Giorgis phenomenological analysis as modified by Malterud.Results and conclusionLeadership was perceived as an essential component in trauma management. The ideal leader should be an experienced surgeon, have extensive knowledge of trauma care, communicate clearly and radiate confidence. Team leaders were reported to have little trauma experience, and the team leaders interviewed requested more guidance and supervision. The need for better training of trauma teams and especially team leaders requires further investigation and action.

Prehospital trauma system in a low-income country: system maturation and adaptation during 8 years.

BACKGROUND Of all deaths from injury, 90% occur in low- and middle-income countries, and most of the injured die before reaching a hospital. We have previously shown that a rural trauma system in Northern Iraq significantly reduced mortality in victims of mines and war injuries. In this follow-up study, we evaluated the adaptation and maturation of the system to changing injury patterns, focusing on mortality, time intervals from injury to medical help, and treatment effect on the physiologic impact of injuries. METHODS Approximately 6,000 first responders and 88 paramedics were trained in Northern Iraq from 1996 to 2004 and treated 2,349 victims. All patients were prospectively registered with monitoring of time intervals, interventions performed, prehospital treatment effect, and mortality. RESULTS Injury pattern changed markedly during the study period, with penetrating injuries decreasing from 91% to 15%. Mortality in victims of mines and war injuries (n = 919) decreased from 28.7% to 9.4% (p = 0.001), as did the time interval from injury to first medical help, from 2.4 hours to 0.6 hours (p = 0.002). The prehospital treatment effect improved significantly in the later part of the study period compared with the first years (p < 0.0005). Improvement was maintained in new injury groups. Retention of paramedics in the program was 72% after 8 years. CONCLUSIONS This low-tech prehospital emergency system designed for dealing with penetrating trauma matured by reducing time to first medical help and by improving physiologic parameters after prehospital treatment during the 8-year study period. The program adapted to changing injury patterns without compromising 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.

A systematic literature review on first aid provided by laypeople to trauma victims

Death from trauma is a significant and international problem. Outcome for patients suffering out‐of‐hospital cardiac arrests is significantly improved by early cardiopulmonary resuscitation. The usefulness of first aid given by laypeople in trauma is less well established. The aim of this study was to review the existing literature on first aid provided by laypeople to trauma victims and to establish how often first aid is provided, if it is performed correctly, and its impact on outcome. A systematic review was carried out, according to preferred reporting items for systematic reviews and meta‐analysis (PRISMA) guidelines, of all studies involving first aid provided by laypeople to trauma victims. Cochrane, Embase, Medline, Pubmed, and Google Scholar databases were systematically searched. Ten eligible articles were identified involving a total of 5836 victims. Eight studies were related to patient outcome, while two studies were simulation based. The proportion of patients who received first aid ranged from 10.7% to 65%. Incorrect first aid was given in up to 83.7% of cases. Airway handling and haemorrhage control were particular areas of concern. One study from Iraq investigated survival and reported a 5.8% reduction in mortality. Two retrospective autopsy‐based studies estimated that correct first aid could have reduced mortality by 1.8–4.5%. There is limited evidence regarding first aid provided by laypeople to trauma victims. Due to great heterogeneity in the studies, firm conclusions can not be drawn. However, the results show a potential mortality reduction if first aid is administered to trauma victims. Further research is necessary to establish this.

Team-oriented training for damage control surgery in rural trauma: a new paradigm.

BACKGROUND The geography of Norway has led to an initiative to train teams from rural hospitals in damage control surgery using a team-oriented approach based on Crew Resource Management. Our aim was to evaluate this approach and its impact on trauma care in rural hospitals across Norway. METHODS Thirty-eight teams from 21 hospitals participated in 10 courses (during the years 2003-2006) where providers from the same hospital trained as a team. Each course consisted of interactive lecture modules and operative sessions on live porcine models that emphasize communication, collaboration and team-based problem solving. The data collection tools were a postcourse questionnaire and a phone survey of participating hospitals. RESULTS Teams consisted of surgeons (34%), operating room nurses (35%), and anesthesiology staff (31%). Almost all course participants (N = 228, 99%) reported a dramatic increase in their proficiency with damage control techniques. There was a mean increase of 2.3 points in proficiency with extraperitoneal pelvic packing and 1.5 points with emergency thoracotomy on a 5-step Likert scale. The team approach was perceived as crucial by 218 (94%) of participants. The phone survey revealed 12 cases of lifesaving rural damage control operations by course participants in the past 3 years (estimated cost:

Mortality in land-mine accidents in Iran.

15,075 per life saved). Of the 18 hospitals surveyed, 17 modified their trauma protocols as a result of the course. CONCLUSION Teaching damage control surgery using a team-oriented approach is an innovative educational method for rural hospitals.

A consensus based template for reporting of pre-hospital major incident medical management

OBJECTIVE To study the rate of prehospital mortality before establishment of a rescue system for victims of land-mines in Iran. METHOD Survey at rural clinics in mine-affected areas, and retrospective review of public patient records. RESULTS A total of 36.4% of casualties from land-mines in the study area died during the period of 1989-1999. The mortality seems highest in those victims who were torso injured. CONCLUSION The mortality rate from accidents involving land-mines in the study area was high. Most fatalities seemingly occurred in the prehospital setting.

Rural High North: A High Rate of Fatal Injury and Prehospital Death

BackgroundStructured reporting of major incidents has been advocated to improve the care provided at future incidents. A systematic review identified ten existing templates for reporting major incident medical management, but these templates are not in widespread use. We aimed to address this challenge by designing an open access template for uniform reporting of data from pre-hospital major incident medical management that will be tested for feasibility.MethodsAn expert group of thirteen European major incident practitioners, planners or academics participated in a four stage modified nominal group technique consensus process to design a novel reporting template. Initially, each expert proposed 30 variables. Secondly, these proposals were combined and each expert prioritized 45 variables from the total of 270. Thirdly, the expert group met in Norway to develop the template. Lastly, revisions to the final template were agreed via e-mail.ResultsThe consensus process resulted in a template consisting of 48 variables divided into six categories; pre-incident data, Emergency Medical Service (EMS) background, incident characteristics, EMS response, patient characteristics and key lessons.ConclusionsThe expert group reached consensus on a set of key variables to report the medical management of pre-hospital major incidents and developed a novel reporting template. The template will be freely available for downloading and reporting on http://www.majorincidentreporting.org. This is the first global open access database for pre-hospital major incident reporting. The use of a uniform dataset will allow comparative analysis and has potential to identify areas of improvement for future responses.