The State of Affairs
The morbidity and mortality of trauma on a global perspective is humbling. Aside from HIV/AIDS and TB, trauma is the chief cause of mortality for 15 to 45 years of age (based on 2002 WHO data). 5.8 million deaths annually. 5.2 million of those deaths, or 90%, occur in low-and-middle-income countries (LMIC’s). Prehospital care in LMIC’s varies immensely. Total prehospital time, the training level of prehospital providers, transportation method, and access to emergency medical systems (EMS) are some of the better described aspects of prehospital care in LMIC’s. The attributes of the prehospital health care delivery system differ significantly on a country by country basis. However, overall trends persist:
Increasing population and urbanization → increasing demand for prehospital care
Population wide access to EMS is a challenge.
The WHO recommends a single, nationally available contact number (think 911)
Rural areas remain comparatively underserved.
In some areas of rural Africa, prehospital times are often as long as 1-2 days
Prehospital provider skill level and mode of transportation are often less than ideal
The most common mode of EMS transport in Sri Lanka remains the rickshaw
Firefighters and police often provide the bulk of prehospital transport/care
Most countries have nationally instituted regulations for ambulances, though exceptions remain
Approach to the Problem
Training: First Aid, BLS, and ACLS
The fact remains that many providers of prehospital care in LMIC’s have very limited experience and bystanders often have less. It is often taken for granted that a vast amount of community members are CPR certified in the U.S. And this is not the universal truth. In the bulk of the developing world, first responders are rarely BLS trained; although, they often may have basic First Aid training. Studies have shown us that even basic First Aid training is efficacious. In landmine infested areas of Cambodia and Iraq, simply creating a volunteer network of First Aid certified individuals armed with basic supplies saw mortality in trauma victims drop from 40% to 8%.
Standardization of training of first responders remains another large issue in LMIC’s as well. In a recent article studying prehospital care in LMIC’s, nearly half the countries surveyed had no method of certification of their EMS providers. This calls into question the standardization of their training and may indicate the lack of a centralized, governmental focus on the importance of prehospital care.
Access to Early Intervention: The “Golden Hour” and 3 Phases of Deaths from Trauma
While evidence of the “Golden Hour” remains somewhat controversial (and is beyond the scope of this discussion), it is well established that mortality from trauma occurs in a 3 phase pattern. The initial phase occurs within the first seconds to minutes. The second is often within several hours, and the third is in the following days. The second phase is the targeted phase and the concept behind the “scoop and run” approach to trauma, as opposed to “stay and play.”
The ability of prehospital teams to perform maneuvers such as spine immobilization, fluid resuscitation, or intubation remains extremely varied. Available evidence indicates that the simple presence and availability of prehospital trauma systems decreases trauma mortality significantly. For example, a 10 year cohort studied while a prehospital trauma system (including first responders followed by paramedics) was being implemented in Iraq reduced trauma related mortality from 17% to 4%. Two key factors to the mortality benefit were the decreased response time by the EMS system (think trauma mortality Phase 2) and bystander interventions.
Discussing access, universal emergency telephone numbers have been adopted by almost all LMIC’s, but response time less than 1 hour is often as low as 5% in some developing nations. The study quoted above shows that early intervention is key in trauma, but infrastructure is not always in place which effectively delays transit times on the scale of hours to days.
Potential Barriers and Pitfalls
The most commonly cited cause of development in prehospital care in LMIC’s according to a recent publication by Neilsen et al.
Tied for second most commonly cited barriers to prehospital care development. Engineering the infrastructure required for effective prehospital care is an enormous task that benefits from central standardization.
Accreditation for Providers
As discussed above, accreditation and standardized training for providers is often lacking. The general public’s knowledge of basic first aid is an area for improvement as well.
Lack of Infrastructure
Roads, ambulances, common access numbers, and providers with their associated costs all stand out as barriers to the implementation of effective prehospital care.
Trauma is one of the most important causes of morbidity and mortality worldwide. Time zero starts as soon as the event takes place, not upon arrival in Emergency Departments. In LMIC’s, there are many barriers to the implementation of effective prehospital care systems, and resources taken for granted in developed nations often don’t exist. However, expanding the currently available prehospital care systems is a medical necessity with a well demonstrated, evidence based mortality benefit. From increasing First Aid training across the general public to a centralized, governmental focus on EMS- including funding, standardization, and administrative leadership - there are many areas for that we may focus on for improvement.
- Anand L, Kapoor D. Prehospital trauma care services in developing countries. Anesthesia, Pain, and Intensive Care. 2013.
- Husum H, Gilbert M, Wisborg T, Van Heng Y, Murad M. Rural prehospital trauma systems improve trauma outcome in low-income countries: a prospective study from North Iraq and Cambodia. J Trauma. 2003 Jun; 54(6):1188-96.
- Murad MK, Larsen S, Husum H. Prehospital trauma care reduces mortality. Ten year results from a time-cohort and trauma audit study in Iraq. Sacnd J Trauma Resusc Emerg Med 2012 Feb 3; 20:13. doi: 10.1186/1757-7241-20-13.
- Nielsen K, Mock C, Joshipura M, Rubiano AM, Zakariah A, Rivara F. Assessment of the status of prehospital care in 13 low- and middle-income countries. Prehosp Emerg Care. 2012 Jul-Sep;16:381-9.
Peer Review by Dustin Calhoun, MD
- Assistant Professor, University of Cincinnati Dept. of Emergency Medicine
- Completed EMS Fellowship at University of Cincinnati
Dr. Winders’ article does an excellent job of summarizing many of the challenges facing those working to create, mature, and/or bolster EMS systems in LMICs. In the US and other nations like it, where we tinker with the order of procedures and exactly which piece of equipment to use to fine tune desired outcomes, it is easy to fail to comprehend the task facing developing systems. Even ignoring the obvious elephant in the room, funding and administrative support, which nearly all systems must overcome, each system finds its own unique morass of difficulties. Attempts to apply European and US EMS models to a heavily water transport based chain of islands in the south pacific requires an entirely different set of adaptations than doing so to mountainous Bhutan. Solving these sorts of problems requires strong collaboration between expertise developed through involvement with “traditional ems” and expertise held only by local parties. On the other hand, solving problems such as EMS training in areas with limited literacy or the complexity of EMS response with unmarked roads with no addresses and long-distance transports without the luxury of HEMS, often requires the development of an entirely new knowledge base. Additionally, while certainly much benefit can be produced by philanthropic involvement from developed nations, we must always keep an eye toward an ultimate goal of local independence.