Prehospital Trauma Care Services in Developing Countries

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REVIEW ARTICLE Prehospital trauma care services in developing countries Lakesh Kumar Anand, MD, FCCP, FIMSA, FCCS, MAMS*, Manpreet Singh, MD, FCCP, FIMSA, FACEE, FCCS**, Dheeraj Kapoor, MD, FCCP, FACEE, FCCS***

*Associate Professor; **Assistant Professor Department of Anaesthesia & Intensive Care, Government Medical College & Hospital, Sector 32, Chandigarh (India)

Correspondence: Dr Manpreet Singh, Department of Anaesthesia & Intensive Care, Government Medical College and Hospital, Sector 32, Chandigarh (India); E-mail: [email protected] ABSTRACT Trauma is a leading cause of death and disability especially amongst young people. Prehospital trauma care service remains a dynamic field of medicine for care of trauma patients. The goal of prehospital emergency care system should be to match the needs of the patients to the available resources so that optimal, prompt and cost-effective care can be offered. For bridging the wide gap between the actual and expected level of care, the urgent need must be appreciated by the community, administration, medical professionals and very positive steps should be taken to meet the future challenges. The authors included a “snapshot” of current articles applicable to prehospital trauma care in developing countries. The current review aims to explore the concept of “golden hour” and objectives, controversies and existing status of prehospital trauma care service using the recent evidence based literature in developing countries. Keywords: Prehospital trauma care service; Trauma care; Golden hour; Prehospital trauma Citation: Anand LK, Singh M, Kapoor D. Prehospital trauma care services in developing countries. Anaesth Pain & Intensive Care 2013;17(1):65-70

INTRODUCTION Unfortunately, prehospital trauma care is not available to most of the world’s population and India is no Management of trauma is a neglected field in exception. developing nations.1 The World Health Organization (WHO) estimates that 5.8 million deaths annually are attributable to injuries, 90% of which occur in THE CONCEPT OF “GOLDEN HOUR” One of the most well known principles in medicine is developing countries 2 with mortality rates expected ‘‘golden hour’’ of trauma , which specifies that patients to increase as these nations further develop, urbanize, outcome are improved when patient is transported to and industrialize.3,4 In addition, an overwhelming a designated trauma centre within an hour of injury. proportion of these deaths occur before patients even Nearly all emergency medical services (EMS) providers reach the hospital.5 Two third (60.7%) of the accident can remember their first exposure to the concept of the victims belonged to the age range of 15 to 44 years.6 This “golden hour” with the idea that trauma patients have is the economically productive age-group and major significantly better survival rates if they reach surgery financial support for their families. Lack of medical within 60 minutes of their injury. The “golden hour” attention attributed to 30 per cent of deaths at site and summarized by the 3R rule of Dr Donald Trunkey, an 80 per cent of the remaining patients died within an academic trauma surgeon, “Getting the right patient to hour of injury (golden hour).7 Most of these deaths the right place at the right time.”10 But the concept of are due to airway management failure, respiratory golden hour is still questionable in most of countries. failure or continuing haemorrhage that are preventable causes with appropriate prehospital and subsequent In a 2001 literature review, Lerner EB et al,11 determined hospital emergency care.8 As a result, governments in the origin of the term “golden hour”. They cited a series developing countries have been attempting to establish of studies discussing the golden hour, but noticed that and strengthen prehospital emergency medical systems those studies often referenced one another and were that can provide patients with prehospital basic life not accompanied by supporting data or references to support (BLS) and transportation to higher care.4,9 other studies. Most frequently the phrase is attributed

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to Cowley, who used it in 1973 with reference to steps: detection, reporting, response, on-scene care, helicopter transport of injured patients in Maryland.12. care in transit and transfer to definitive care18 inspired A retrospective cohort of adult patients with severe from the EMS-symbol or so-called ‘Star of Life’ symbol head injuries was conducted to determine the effect created by the US National Highway Traffic Safety of patient arrival within the golden hour on patient Administration which presents six EMS functions.19 outcomes. Study outcomes were in-hospital mortality Objectives of prehospital trauma care involve prompt and survival to hospital discharge without requiring communication and activation of the system, proper transfer for ongoing rehabilitation or nursing home actions at the scene of the crash by first responders, care. Authors concluded that, a survival benefit exists and the prompt response of the system or simply offer in patients arriving earlier to hospital after severe head fastest possible basic life support includes, airway, injury but the benefit may extend beyond the golden breathing, control of bleeding, and transportation of hour. There was evidence of improved functional the right patient to the right place at right time.3,20 This outcomes in patients arriving within 60 min of injury includes all the appropriate personnel safety precaution, 13 time. Further, according to National Emergency assessment, and treatment of the injured people at the Medical Services Education Standards; “golden period” scene, and transport to trauma care facilities while 14 is still listed as a guideline for teaching trauma care. delivering the necessary medical care before arrival at Although it would seem intuitive that treating patients the hospital. Widespread first-aid training is the most more rapidly results in reduced mortality and secondary important aspect of successful prehospital care. Level of injury but the evidence for the “golden hour” in general care, offered at the site, varies according to the facilities and timing of reaching hospital on patient outcomes is available in a given situation.8 limited. First responder care: Motivated volunteers from Recently, prehospital management and outcome of community, fire-fighters, police, and laypersons polytrauma patients was compared between two trained to provide initial first aid can only offer fastest countries (Scotland and Germany) with differing possible care. For best possible prehospital trauma care approaches to prehospital management. The mean time expected actions from trained bystanders are: getting from an injury to arrival to the emergency department involved, call for help, assessing the safety of the scene, (73 vs. 247 minutes) was longer for the Scottish assessing the victim, capable of appreciating seriousness patients. Despite variation in prehospital transfer of emergency and extend initial care, all will fail if times and interventions, no significant difference was bystanders are not getting involved. demonstrated in revised trauma score upon arrival, or for the unadjusted mortality rates.15 Prospective data Basic prehospital trauma care: This care is provided from 146 EMS transport agencies over a 16 month by the community members exposed to formal period from 2005 to 2007 were analyzed for 806 trauma training in prhospital BLS, scene management, rescue, deaths in a pool of 3656 patients (22% mortality). After stabilisation and transportation of injured persons multivariate, subgroup, and instrumental analyses, no to the definite facility safely without causing further significant association was found between time and harm. Appropriate training had been advocated mortality for any EMS interval (activation, response, for skill enhancement to ensure control of external on-scene, transport, and total time) among injured haemorrhage by direct or indirect pressure, protection 16 patients with physiologic abnormalities. Similarly, of spine, provision of artificial respiration, circulatory 17 data by Lichtveld et al confirms what was noted in a support, oxygen therapy and extrication. Dutch single-centre prospective study in 2007. Among other conclusions, this study also noted “the time Advanced prehospital trauma care: Advanced life interval between the accident and arrival at the hospital support at prehospital level is resource intensive does not appear to affect the risk of death.” Further, and is expected to be provided by highly skilled the pressure to arrive at the hospital within the “golden medical professionals or paramedical staff. The hour” may increase the number of emergent transports, ATLS21 care recommendation includes intravenous which have been demonstrated to increase the risk for fluid therapy, endotracheal intubation, and highly collisions resulting in injury and fatality. invasive interventions such as needle decompression or cricothyroidotomy. Despite the enormous cost involved, this kind of care has not been proved to be OBJECTIVES OF PREHOSPITAL beneficial except for small subset of very critically ill TRAUMA CARE patients. Cost benefit analysis, therefore, is necessary The prehospital trauma care process consists of six key before planning to introduce such facility.8

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CONTROVERSIAL INTERVENTIONS benefit.36,37 Some authorities have instituted selective “Stay and play” versus the “scoop and run” immobilization protocols based on injury mechanism. However, many prehospital protocols advise for Main potential benefit of “scoop and run” is minimise spine immobilization whenever there is potential for delay to definite care, other potential benefit depend on spinal cord injury.37,38 In contrast, prehospital trauma mechanism of injury, specific prehospital interventions life support (PHTLS) course and textbook state that and transport distance. However, the question of spine immobilization is not indicated in patients with attempted “Stay and play” versus “scoop and run” penetrating trauma to the head, neck, or torso without approach in the management of trauma has no clear-cut neurologic deficit or complaint.39 Also supported by 22,23 answer. In real life situation a balance is necessary retrospective analysis of penetrating trauma patients based on the transport distance, pre-hospital resources, in the National Trauma Data Bank, in which patients and mechanisms of injury (blunt vs. penetrating were compared with and without prehospital spine trauma). Decision should be taken by the healthcare immobilization. Authors concluded that, prehospital provider accordingly at the site of incidence. spine immobilization is associated with higher mortality Airway management in penetrating trauma and should not be routinely used 40 Airway management had been advocated in patients in every patient with penetrating trauma. with traumatic brain injury, cervical spine, or thoracic trauma before evacuation unless the same can be PREHOSPITAL TRAUMA STATUS IN performed easily en route.24 Despite the claimed INDIA advantages, prehospital endotracheal intubation (ETI) and rapid-sequence induction performed by Centralised Accident & Trauma Services (CATS), less experienced paramedical staff leads to higher an autonomous body formed in 1991 by the Delhi mortality and poorer neurologic outcomes.25 Studies government was probably the first comprehensive on prehospital ETI showing survival benefit in severe initiative to improve pre-hospital trauma service. head injury,26,27 harm in haemorrhagic state28,29 and Emergency Management and Research Institute no difference30,31 over bag-valve-mask ventilation. Use (EMRI), Hyderabad, Ambulance Access for All (AAA), of ETI in the prehospital care environment remains Foundation and Emergency and Accident Relief Centre controversial.32 Well-designed randomized trials are (EARC) are other service providers in Andhra Pradesh, necessary to assess the efficacy and risks associated Maharashtra and Tamil Nadu respectively. For faster with prehospital ETI. Alternatives to endotracheal response Ambulance Motorbike and Rescue Service intubation including, Laryngeal mask Airway, (AMARS) was initiated in March 2003 by Christian Combitube, Easy tube and Laryngeal tube are easier to Medical College, Ludhiana to offer support in Punjab, 20 insert when compared to endotracheal intubation by Himachal Pradesh, Jammu and Delhi. National Rural providers after minimal training.33,34 Health Mission (NRHM) access started through 108. Recently, Active Network Group of Emergency Life Fluid replacement Savers (ANGELS) access through 102 has been started. Prehospital fluid resuscitation for major trauma is Trained paramedical staffs had been involved by all controversial.32 The harm associated with prehospital the above agencies for offering pre-hospital emergency intravenous (IV) fluid administration is significant for care. victims of trauma. The routine use of prehospital IV Despite increased awareness of the global impact of fluid administration for all trauma patients should be injury and existing system, it has been highlighted41 discouraged. Current trends are for limited crystalloid that the field of trauma care and emergency medicine resuscitation and early use of blood and blood products has not progressed uniformly in the country and it before haemorrhage control in prehospital setting for is still at a primitive stage. Assessment of prehospital both blunt and penetrating injury. Maximum attention care is essential in order to guide future efforts to should be on preventing the lethal triad of trauma: strengthen the overall systems. Nielsen et al42 attempted 25,32,35 hypothermia, acidosis, and coagulopathy. to understand the methods of transport to the Spine Immobilization in Penetrating Trauma hospital, training and certification of EMS providers, Spine immobilization, like IV fluid administration, organization and funding of EMS systems, public access ETI and field stabilization has the potential to delay to prehospital care, and barriers to further prehospital the transport of trauma patients. It is often part of care development in thirteen wide ranges of low- and the current prehospital treatment for patients with middle income countries (LMICs). A standardized penetrating injuries to the head, neck, or torso, although 32-question was derived from needs assessment forms there are no definitive studies that demonstrate its originally created by WHO, based on the prehospital

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trauma care systems publication8 and which had been injured by land mines, war, and traffic accidents were pilot tested and refined in several countries previously. managed by a chain-of-survival trauma system where Information was gathered via a combination of personal non-graduate paramedics were the key care providers. visits, phone interviews, e-mail, and letters. Data were The results of study show that, 37% of the study patients gathered during 2009-2010. Study included EMS had serious injuries with Injury Severity Score ≥ 9. leaders and other key informants in thirteen LMICs. The mean prehospital transport time was 2.5 hours. Result shows that, prehospital care capabilities varied Trauma mortality was reduced from 17% to 4%, significantly, but in general were less developed in low- survival especially improving in major trauma victims. income countries and in rural areas, where utilization of In most patients with airway problems, chest injured, formal EMS was often very low. Commercial drivers, and external haemorrhage, simple life support volunteers, and other bystanders provided a large measures were sufficient to improve physiological proportion of prehospital transport and occasionally severity indicators. It was concluded that, in case also provided first aid in many locations. The most of long prehospital transit times simple life support frequently cited barriers to further development measures by paramedics and lay first responders of prehospital care were inadequate funding (36%). reduce trauma mortality in major injuries. Assigning The next most commonly cited barriers were lack life-saving skills to paramedics and lay people is a key of leadership within the system (18%) and lack of factor for efficient prehospital trauma systems in low- legislation setting standards (18%). Authors concluded resource communities. that, expansion of prehospital care to currently Henry et al45 conducted a systematic review and meta- underserved or unserved areas, especially in rural areas, analysis to assess the effectiveness of prehospital trauma could make use of the already-existing networks of first systems in developing countries. Multiple database responders, such as commercial drivers and laypersons. and bibliography searches were conducted to identify Also, added that efforts to increase their effectiveness, articles assessing the effectiveness of prehospital trauma such as more widespread training accordingly, and systems in developing countries. The primary outcome better encompassing their efforts within formal EMS, was mortality. Secondary outcomes were physiologic are justified. There is a need for increased and more severity score; Injury Severity Score, and prehospital regular funding, integration and coordination among time, appropriate statistical analysis was done. Out existing services, and improved organization and of fourteen studies, eight representing seven countries leadership, as could be accomplished by making EMS (n = 5,607) were included in the meta-analysis. Their administration and leadership a more desirable career pooled estimated results show a 25% decreased risk path. of dying from trauma in areas that have prehospital Later on isolated study appeared form different trauma systems. In-field response time was reduced in countries to provide some useful ideas on prehospital both rural and urban settings. Authors concluded that, solution. Waseem et al43 presented a model of prehospital trauma systems in developing countries, prehospital emergency services which fulfilled the particularly middle-income countries, reduce guidelines of WHO, called Rescue 1122. Authors has mortality. described the process of establishment of the service, Recently, Sun et al46 conducted the study, by using a the organisational structure, the scope of services and prehospital care system and implementation strategy the role it was playing in the healthcare services of the that was more appropriate for a range of conditions in designated region. The system was well supported by South Africa. This model utilizes a core emergency first government funding. Authors agreed that, Rescue aid responders (EFAR) system model that can be locally 1122 has managed to set up a low cost, effective system adapted, along with an implementation strategy that of prehospital care which can be replicated in other could be done in a graduated fashion within an area’s developing countries with little or no modification. means. Motivated local community members were However, prospective and retrospective clinical trials trained to become EFAR who can provide immediate, are needed to verify the efficacy of the system and its on -site care until a transporter can take the patient to role in the healthcare sector. the definite hospital. Management of the system was Study by Murad et al44 evaluated a prehospital done through local community based organizations, trauma system model, to which extent a low-cost trauma which can adapt the model to their communities. system reduces trauma deaths where prehospital transit Within a community, the system was implemented in times are long, and to identify specific life support a graduated manner based on available resources, and interventions that contributed to survival. Ten year was designed to not rely on the whole system being study period from 1997 to 2006; included 2,788 patients implemented first to provide partial function. Authors

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concluded that, strategy was a versatile prehospital CONCLUSION emergency care model with emergency need, and A prehospital trauma care service remains a dynamic shows great promise in making prehospital emergency field of medicine for care of trauma patients. Therefore, care more accessible in under-developed areas of South improvements in the field of trauma services are required Africa. Interestingly, The University of Cape Town’s to ensure “golden hour” compliance for all trauma Division of Emergency Medicine and the Western victims as an achievable goal by coordinating activities Cape’s provincial METRO EMS intend to follow this between prehospital care and specialized hospital care model, along with sharing it with other South African services. One technical aspect of prehospital trauma provinces. care is to improve access and to establish a uniform As developing countries begin to urbanize and grow, emergency access telephone number. Due to great so do their health care needs. The current system heterogeneity in the literature, firm conclusions does not meet the needs of increased mortality from cannot be drawn. However, present literature review trauma. Various factors identified those hinder or provides useful information about the current status facilitate an effective prehospital trauma care process: of prehospital trauma care in developing countries administration and organization, staff qualifications and that will assist in strengthening and expansion of competences, availability and distribution of resources prehospital trauma care. A specific and unique model and communication and transportation are inside the system should be developed to address the needs of the EMS and involvement of other organizations, laypeople trauma patient. The goal should be to get ‘the right and the general infrastructure are outside the EMS. The patient, to the right place, at the right time, to receive core factor is interaction and common understanding the right care’ following trauma. in the medical and non-medical sector.42,47

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