Emergency Medical Service (EMS) systems in developed and developing countries

Effect of private versus emergency medical systems transportation in trauma patients in a mostly physician based system- a retrospective multicenter study based on the TraumaRegister DGU®

Background

The effects of private transportation (PT) to definitive trauma care in comparison to transportation using Emergency Medical Services (EMS) have so far been addressed by a few studies, with some of them finding a beneficial effect on survival. The aim of the current study was to investigate epidemiology, pre- and in-hospital times as well as outcomes in patients after PT as compared to EMS recorded in the TraumaRegister DGU®.

Methods

All patients in the database of the TraumaRegister DGU® (TR-DGU) from participating European trauma centers treated in 2009 to 2013 with available data on the mode of transportation, ISS ≥ 4 and ICU treatment were included in the study. Epidemiological data, pre- and in-hospital times were analysed. Outcomes were analysed after adjustment for RISC-II scores.

Results

76,512 patients were included in the study, of which 1,085 (1.4 %) were private transports. Distribution of ages and trauma mechanisms showed a markedly different pattern following PT, with more children < 15 years treated following PT (3.3 % EMS vs. 9.6 for PT) and more elderly patients of 65 years or older (26.6 vs 32.4 %). Private transportation to trauma care was by far more frequent in Level 2 and 3 hospitals (41.2 % in EMS group vs 73.7 %). Median pre-hospital times were also reduced following PT (59 min for EMS vs. 46 for PT). In-hospital time in the trauma room (66 for EMS vs. 103 min for PT) and time to diagnostics were prolonged following PT. Outcome analysis after adjustment for RISC-II scores showed a survival benefit of PT over EMS transport (SMR for EMS 1.07 95 % CI 1.05–1.09; for PT 0.85 95 % CI 0.62–1.08).

Discussion

The current study shows a distinct pattern concerning epidemiology and mechanism of injury following PT. PT accelerates the median pre-hospital times, but prolongs time to diagnostic measures and time in the trauma room.

Conclusions

In this distinct collective, PT seemed to lead to a small benefit in terms of mortality, which may reflect pre-hospital times, pre-hospital interventions or other confounders.

Dead on arrival in a low-income country: results from a multicenter study in Pakistan

BACKGROUND

This study assessed the characteristics of dead on arrival (DOA) patients in Pakistan.

METHODS

Data about the DOA patients were extracted from Pakistan National Emergency Department Surveillance study (Pak-NEDS). This study recruited all ED patients presenting to seven tertiary care hospitals during a four-month period between November 2010 and March 2011. This study included patients who were declared dead-on-arrival by the ED physician.

RESULTS

A total of 1,557 DOA patients (7 per 1,000 visits) were included in the Pak-NEDS. Men accounted for two-thirds (64%) of DOA patients. Those aged 20-49 years accounted for about 46% of DOA patients. Nine percent (n = 72) of patients were brought by ambulance, and most patients presented at a public hospital (80%). About 11% of DOA patients had an injury. Factors significantly associated (p < 0.05) with ambulance use were men (adjusted odds ratio [aOR] = 2.72), brought to a private hospital (OR = 2.74), and being injured (aOR = 1.89). Cardiopulmonary resuscitation (CPR) was performed on 6% (n = 42) of patients who received treatment. Those brought to a private hospital were more likely to receive CPR (aOR = 2.81).

CONCLUSION

This study noted a higher burden of DOA patients in Pakistan compared to other resourceful settings (about 1 to 2 per 1,000 visits). A large proportion of patients belonging to productive age groups, and the low prevalence of ambulance and CPR use, indicate a need for improving the prehospital care and basic life support training in Pakistan.

Ambulance use in Pakistan: an analysis of surveillance data from emergency departments in Pakistan

Background

The utilization of ambulances in low- and middle-income countries is limited. The aim of this study was to ascertain frequency of ambulance use and characteristics of patients brought into emergency departments (EDs) through ambulance and non-ambulance modes of transportation.

Methods

The Pakistan National Emergency Departments Surveillance (Pak-NEDS) was a pilot active surveillance conducted in seven major tertiary-care EDs in six main cities of Pakistan between November 2010 and March 2011. Univariate and multivariate logistic regression was performed to investigate the factors associated with ambulance use.

Results

Out of 274,436 patients enrolled in Pak-NEDS, the mode of arrival to the ED was documented for 94. 9% (n = 260,378) patients, of which 4.1% (n = 10,546) came to EDs via ambulances. The mean age of patients in the ambulance group was significantly higher compared to the mean age of the non-ambulance group (38 ± 18.4 years versus 32.8 ± 14.9 years, p-value < 0.001). The most common presenting complaint in the ambulance group was head injury (12%) while among non-ambulance users it was fever (12%). Patients of all age groups were less likely to use an ambulance compared to those >45 years of age (p-value < 0.001) adjusted for gender, cities, hospital type, presenting complaint group and disposition. The adjusted odds ratio of utilizing ambulances for those with injuries was 3.5 times higher than those with non-injury complaints (p-value < 0.001). Patients brought to the ED by ambulance were 7.2 times more likely to die in the ED than non-ambulance patients after adjustment for other variables in the model.

Conclusion

Utilization of ambulances is very low in Pakistan. Ambulance use was found to be more among the elderly and those presenting with injuries. Patients presenting via ambulances were more likely to die in the ED.

Trauma Registry Development for Jos University Teaching Hospital: Report of the First Year Experience

Adequate intervention in trauma management and prevention requires a well-documented database for objective study of the disease characteristics, hence the need for a trauma registry. The aim and objective of this study is to document in a database all patients admitted in our hospital following trauma. This study was conducted at the Jos University Teaching Hospital, Jos, Plateau State, Nigeria. Beginning 1 January 2012, data was collected on a trauma data sheet and transferred to a 3-page, 80-point questionnaire on Epi info3.5.2 software and stored in a standalone desktop computer. Four hundred fifty-nine patients were registered. Road traffic collisions were the most common causes of trauma, 312 (70.0 %), followed by gunshots, 58 (12.6 %). Mechanism of injury was blunt in 307 patients (66.9 %) and penetrating in 152 patients (33.1 %). Only 9 patients (2.0 %) were brought in by ambulance; majority came by public transportation, 401 (87.4 %). Eighty four patients (18.3 %) suffered various complications; 342 (74.5 %) were discharged home in satisfactory condition, and there were 32 hospital mortalities (7.0 %). Challenges encountered include difficulty in data collection, lack of computer software and internet access, no dedicated registry staff and no funding to engage, train and retain data gathering and management personnel. Our results provide data in support of the known epidemiology of trauma in our environment. Challenges encountered can be overcome using local assets and resources.

Does harmonization of payment mechanisms enhance equitable health outcomes in delivery of emergency medical services in Thailand?

There are different reimbursement rates by the various insurance schemes in Thailand, which include the Universal Coverage scheme (UCS), civil servant medical benefit scheme (CSMBS) and social security scheme (SSS). Hence, there are concerns about inequitable care standards. Harmonization of the rates of emergency medical services has been started since April 2012. This study analyzed the impact of harmonization on clinical outcomes in private hospitals. Analysis of 22 900 records of the dataset accrued from April 2012 to June 2013 using multiple logistic modelling revealed that beneficiaries under UCS were the worst off [Odds ratio 2.56 95% of confidence interval: 2.35 to 2.80 for non-trauma and 2.19 (1.59-3.0) for trauma, corresponding to 21.26 and 25.09% of bad outcomes, respectively] in terms of not improved or dead outcomes at discharge compared with those under the CSMBS (8.45 and 12.78%, respectively) controlling for age, sex, hospital location, triage priority code, length of stays and adjusted Relative weight (RW) score. Using propensity score, matching analysis found the outcome rates of not improved including dead were highest in UCS 26.27% for trauma and 21.26% for non-trauma patients. Payment mechanism alone is inadequate to ensure equitable distribution of health outcomes in provision of emergency medical care by private providers in urban settings across the country. A secondary finding was that patients accessing hospital services directly showed better improvement or lower in-hospital mortality compared with access through formal pre-hospital means (P < 0.001). Plausible explanations have been discussed with policy implications and recommendations for further studies.

Pre-hospital care among victims of road traffic accident in a rural area of Tamil Nadu: A cross-sectional descriptive study

Background:

The World Health Organization has estimated that globally almost 1.24 million people die annually on the world's roads. The aim of the study was to assess the attributes of pre-hospital care in road traffic accidents (RTAs) victim brought to the health care establishment and to evaluate the pre-hospital trauma care provided in the rural areas of Kancheepuram district of Tamil Nadu.

Materials and Methods:

A cross-sectional descriptive study of 3 months duration (June 2014 to August 2014) was conducted in the Shri Sathya Sai Medical College and Research Institute, Kancheepuram. The method of sampling was universal sampling and all RTA victims satisfying the inclusion criteria were included in the study. During the entire study duration, total 200 RTA victims were included. A pre-tested semi-structured questionnaire was used to elicit the desired information after the victims of RTAs are stabilized. Ethical clearance was obtained from the Institutional Ethics Committee prior to the start of the study. Written informed consent was obtained from the study participants (patient/guardian of children) before obtaining any information from them. Data entry and statistical analysis were done using SPSS version 18. Frequency distributions and percentages were computed for all the variables.

Results:

Majority of the RTA victims 158 (79%) were from the age-group of 15-45 years. Most of the accidents were reported in night time [77 (38.5%)], on week-ends [113 (56.5%)], and involved two-wheelers [153 (76.5%)]. Almost 66 (33%) of the victims were not aware of the existence of emergency ambulance services. Also, only 15 (7.5%) victims were brought to the hospital in the emergency ambulance, of which only 3 victims were accompanied by a doctor.

Conclusion:

To conclude, the study indicates that a significant proportion of people were unaware about the emergency trauma ambulance services and the existing pre-hospital care services lack in multiple dimensions in a rural area of South India.

Pre-hospital burn mission as a unique experience: a qualitative study

INTRODUCTION

A thorough understanding of experiences related to pre-hospital emergency care of burns is a prerequisite of skill promotion for medical personnel. The aim of the present study was to evaluate the experiences of pre-hospital emergency personnel during burn accidents.

METHODS

The present qualitative study was performed using a content analysis method. In total, 18 Iranian emergency care personnel participated in the study. A purposeful sampling method was applied until reaching data saturation. Data were collected using semi-structured interviews and field observations. Afterwards, the gathered data were analyzed through face content analysis.

RESULTS

By analyzing 498 primary codes, four main categories; the nature of burn care, tension at the accident scene, gradual job 'burnout', and insufficient information, were extracted from the experiences of pre-hospital emergency personnel during burn care. These categories each included several sub-categories, which were classified according to their significant characteristics.

CONCLUSION

This study showed that different factors affect the quality of pre-hospital clinical services for burns. Authorities and health system administrators should consider the physical and psychological health of their staff, and assign policies to improve the quality of pre-hospital medical care. According to the present results, it is recommended that the process of pre-hospital emergency care for burns be investigated further.

Overview of the shenzhen emergency medical service call pattern

BACKGROUND

In Shenzhen, the Emergency Medical Service (EMS) system has been in service since 1997. This study aims to examine the operation of Shenzhen 120 EMS center and to identify the reasons of calling EMS.

METHODS

In this retrospective quantitative descriptive study, the data from the Shenzhen 120 EMS registry in 2011 were analyzed.

RESULTS

Shenzhen 120 EMS center is a communication command center. When the number of 120 are dialed, it is forwarded to the closest appropriate hospital for ambulance dispatch. In 2011, the Shenzhen 120 EMS center received 153 160 ambulance calls, with an average of 420 calls per day. Calling emergency services was mainly due to traffic accidents. Trauma and other acute diseases constituted a majority of ambulance transports. The adult patients aged 15-60 years are the principal users of EMS. There are no recognized 'paramedic' doctors and nurses. The pre-hospital emergency service is under the operation of emergency departments of hospitals. Shenzhen at present does not have specialized pre-hospital training for doctors and nurses in post-trauma management. Moreover, specialized pre-hospital training, financial support, and public health education on proper use of EMS should be emphasized.

CONCLUSION

The Shenzhen 120 EMS center has its own epidemiology characteristics. Traumatic injury and traffic accident are the main reasons for calling ambulance service. In-depth study emphasizing the distribution and characteristics of trauma patients is crucial to the future development of EMS.

Prehospital Care and In-hospital Mortality of Trauma Patients in Iran

INTRODUCTION

The aim of this study was to determine the effect of prehospital time and advanced trauma life support interventions for trauma patients transported to an Iranian Trauma Center.

METHODS

This study was a retrospective study of trauma victims presenting to a trauma center in central Iran by Emergency Medical Services (EMS) and hospitalized more than 24 hours. Demographic and injury characteristics were obtained, including accident location, damaged organs, injury mechanism, injury severity score, prehospital times (response, scene, and transport), interventions and in-hospital outcome.

RESULTS

Two thousand patients were studied with an average age of 36.3 (SD = 20.8) years; 83.1% were male. One hundred twenty patients (6.1%) died during hospitalization. The mean response time, at scene time and transport time were 6.6 (SD = 3), 11.1 (SD = 5.2) and 12.8 (SD = 9.4), respectively. There was a significant association of longer transport time to worse outcome (P = .02). There was a trend for patients with transport times >10 minutes to die (OR: 0.8; 95% CI, 0.1-6.59). Advanced Life Support (ALS) interventions were applied for patients with severe injuries (Revised Trauma Score ⩽7) and ALS intervention was associated with more time on scene. There was a positive association of survival with ALS interventions applied in suburban areas (P = .001).

CONCLUSION

In-hospital trauma mortality was more common for patients with severe injuries and long prehospital transport times. While more severely injured patients received ALS interventions and died, these interventions were associated with positive survival trends when conducted in suburban and out-of-city road locations with long transport times.

Employment of telemedicine in emergency medicine. Clinical requirement analysis, system development and first test results

OBJECTIVES

Demographic change, rising co-morbidity and an increasing number of emergencies are the main challenges that emergency medical services (EMS) in several countries worldwide are facing. In order to improve quality in EMS, highly trained personnel and well-equipped ambulances are essential. However several studies have shown a deficiency in qualified EMS physicians. Telemedicine emerges as a complementary system in EMS that may provide expertise and improve quality of medical treatment on the scene. Hence our aim is to develop and test a specific teleconsultation system.

METHODS

During the development process several use cases were defined and technically specified by medical experts and engineers in the areas of: system administration, start-up of EMS assistance systems, audio communication, data transfer, routine tele-EMS physician activities and research capabilities. Upon completion, technical field tests were performed under realistic conditions to test system properties such as robustness, feasibility and usability, providing end-to-end measurements.

RESULTS

Six ambulances were equipped with telemedical facilities based on the results of the requirement analysis and 55 scenarios were tested under realistic conditions in one month. The results indicate that the developed system performed well in terms of usability and robustness. The major challenges were, as expected, mobile communication and data network availability. Third generation networks were only available in 76.4% of the cases. Although 3G (third generation), such as Universal Mobile Telecommunications System (UMTS), provides beneficial conditions for higher bandwidth, system performance for most features was also acceptable under adequate 2G (second generation) test conditions.

CONCLUSIONS

An innovative concept for the use of telemedicine for medical consultations in EMS was developed. Organisational and technical aspects were considered and practical requirements specified. Since technical feasibility was demonstrated in these technical field tests, the next step would be to prove medical usefulness and technical robustness under real conditions in a clinical trial.

A plea for Croatian trauma system

This paper provides an insight into Croatian health system with special focus on trauma care. The current situation is explained from a domestic point of view, but an independent review by foreign observers is also included. Fragmented approach to the treatment of injured patients in Croatia should be replaced by networking of health care componenets into a unique chain of help. The concept and five methodological steps in the development of a succesfull trauma system are presented. A good start is definitely a reorganization of existing knowledge on the basis of internationally licesed courses and the adoption of trauma registry as a standard for future discussion. Individual components of the trauma system can not be separately "optimized" so clinical and financial decisions should be planned exclusively on the integral level.

Trauma registries in developing countries: a review of the published experience

BACKGROUND

The burden of injury is greatest in developing countries. Trauma systems have reduced mortality in developed countries and trauma registries are known to be integral to monitoring and improving trauma care. There are relatively few trauma registries in developing countries and no reviews describing the experience of each registry. The aim of this study was to examine the collective published experience of trauma registries in developing countries.

METHODS

A structured review of the literature was performed. Relevant abstracts were identified by searching databases for all articles regarding a trauma registry in a developing country. A tool was used to abstract trauma registry details, including processes of data collection and analysis.

RESULTS

There were 84 articles, 76 of which were sourced from 47 registries. The remaining eight articles were perspectives. Most were from Iran, followed by China, Jamaica, South Africa and Uganda. Only two registries used the Injury Severity Score (ISS) to define inclusion criteria. Most registries collected data on variables from all five variable groups (demographics, injury event, process of care, injury severity and outcome). Several registries collected data for less than a total of 20 variables. Only three registries measured disability using a score. The most commonly used scores of injury severity were the ISS, followed by Revised Trauma Score (RTS), Trauma and Injury Severity Score (TRISS) and the Kampala Trauma Score (KTS).

CONCLUSION

Amongst the small number of trauma registries in developing countries, there is a large variation in processes. The implementation of trauma systems with trauma registries is feasible in under-resourced environments where they are desperately needed.

Determining and Prioritizing the Organizational Determinants of Emergency Medical Services (EMS) in Iran

Background

Improving the organization of pre-hospital emergency to provide emergency medical services (EMS), as a part of health system, plays an important role in timely and properly response to incidents, as well as, reducing mortalities and disabilities.

Objective

This study was conducted to determine the organizational determinants of emergency medical services in Iran and analyze their relationship and prioritize them.

Materials and Methods

The present study is kind of descriptive and cross-sectional study that has been conducted on the first half of 2010 using DEMATEL method (a group decision-making technique). Required data were collected using a questionnaire from a sample of 30 Iranian experts in pre-hospital emergency, who were selected using available sampling method.

Results

The determinants of establishing an independent EMS organization as a policy maker and observer organization, providing services through public organizations such as Emergency 115, private organizations partnership in pre-hospital emergency system, and integrating pre-hospital and hospital emergency under single supervision and management were determined as organizational determinants. Also, establishing an independent EMS organization and integrating pre-hospital and hospital emergency under single supervision and management were determined as the most affecting and affected organizational determinants, respectively, with the coordinates (1.01 and 1.01) and (0.85 and - 0.85) in the pre-hospital emergency organizational determinants graph.

Conclusions

Emergency medical services should be considered as a system with its independent components. Establishing an independent EMS organization, integrating pre-hospital and hospital emergency under single supervision and management, as well as, extending the possibility of providing EMS through private sector are essential in order to make fundamental reforms in providing emergency medical services in Iran.

A comparison of the treatment of severe injuries between the former East and West German States

BACKGROUND

The annual number of persons killed in road-traffic accidents in Germany declined by 36% from 2001 to 2008, yet official traffic statistics still reveal a marked difference in fatalities between the federal states of the former East and West Germany twenty years after German reunification.

METHODS

We retrospectively analyzed data from the Trauma Registry of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie; TR-DGU). Patients receiving primary treatment that had an Injury Severity Score (ISS) of 9 or above were analyzed separately depending on whether they were treated in the former East Germany or the former West Germany.

RESULTS

Data were obtained from a total of 26 866 road-accident trauma cases. With Berlin excluded, 2597 cases (10.2%) were from the former East Germany (EG), and 22 966 (89.9%) were from the former West Germany (WG). The percentage of the population living in these two parts of the country is 16.7% and 83.3%, respectively. The two groups did not differ significantly in either the mortality of injuries (EG 15.8%, WG 15.7%) or in the standardized mortality rate (0.89 [EG] vs. 0.88 [WG]). Over the years 2002-2008, the mean time to arrival of the emergency medical services on the scene was 19 minutes (EG) vs. 17 minutes (WG), and the mean time to arrival in hospital was 76 minutes (EG) vs. 69 minutes (WG).

CONCLUSION

Among the hospitals whose cases are included in the TR-DGU, there is no significant difference between the former East and West Germany with respect to mortality or any other clinically relevant variable. Hypothetically, the higher rate of death from road-traffic accidents in the former East Germany, as revealed by national traffic statistics, might be attributable to a difference in the quality of care received by trauma patients, but no such difference was found. Other potential reasons for it might be poorer road conditions, more initially fatal accidents, and lower accessibility of medical care in less densely populated areas.

Pre-hospital trauma care in road traffic accidents in kashan, iran

Background

Iran has one of the highest rates of road traffic accidents (RTAs) worldwide. Pre-hospital trauma care can help minimize many instances of traffic-related mortality and morbidity.

Objectives

The aim of this study was to assess the characteristics of pre-hospital care in patients who were injured in RTAs, admitted to hospital. The focus was mainly directed at evaluating pre-hospital trauma care provided in city streets and roads out of the city.

Patients and Methods

This retrospective study was carried out on all trauma patients, transported by the emergency medical service (EMS) system, who were admitted to Kashan Shahid-Beheshti hospital during the period from March 2011 to March 2012. The patients’ demographic data, location of accident, damaged organs, mechanism of injury, injury severity, pre-hospital times (response, scene, transport), pre-hospital interventions and outcomes, were extracted from the data registry and analyzed through descriptive statistics using SPSS 18 software.

Results

Findings of this study showed that, 75% of RTAs occurred on city streets (n = 1 251). Motor-car accidents were the most frequent mechanism of RTA on city streets (n = 525) (42%), while car rollover was the most frequent mechanism of RTA on roads out of the city (n = 155) (44.4%). The mean pre-hospital time intervals (min); response, scene, and transport for all patients were 6.6 ± 3.1, 10.7 ± 5 and 13 ± 9.8, respectively. The mean pre-hospital time intervals (response, scene, transport) in roads out of the city were higher than those in city streets. There was a significant difference (P = 0.04) in the mortality rates due to RTAs between city streets (n = 46) and roads out of the city (n = 32).

Conclusions

In comparison with road traffic accidents on city streets, trauma patients in RTAs on roads out of the city have longer pre-hospital time intervals and more severe injuries; therefore, this group needs more pre-hospital resuscitation interventions.

A validation of ground ambulance pre-hospital times modeled using geographic information systems

Background

Evaluating geographic access to health services often requires determining the patient travel time to a specified service. For urgent care, many research studies have modeled patient pre-hospital time by ground emergency medical services (EMS) using geographic information systems (GIS). The purpose of this study was to determine if the modeling assumptions proposed through prior United States (US) studies are valid in a non-US context, and to use the resulting information to provide revised recommendations for modeling travel time using GIS in the absence of actual EMS trip data.

Methods

The study sample contained all emergency adult patient trips within the Calgary area for 2006. Each record included four components of pre-hospital time (activation, response, on-scene and transport interval). The actual activation and on-scene intervals were compared with those used in published models. The transport interval was calculated within GIS using the Network Analyst extension of Esri ArcGIS 10.0 and the response interval was derived using previously established methods. These GIS derived transport and response intervals were compared with the actual times using descriptive methods. We used the information acquired through the analysis of the EMS trip data to create an updated model that could be used to estimate travel time in the absence of actual EMS trip records.

Results

There were 29,765 complete EMS records for scene locations inside the city and 529 outside. The actual median on-scene intervals were longer than the average previously reported by 7–8 minutes. Actual EMS pre-hospital times across our study area were significantly higher than the estimated times modeled using GIS and the original travel time assumptions. Our updated model, although still underestimating the total pre-hospital time, more accurately represents the true pre-hospital time in our study area.

Conclusions

The widespread use of generalized EMS pre-hospital time assumptions based on US data may not be appropriate in a non-US context. The preference for researchers should be to use actual EMS trip records from the proposed research study area. In the absence of EMS trip data researchers should determine which modeling assumptions more accurately reflect the EMS protocols across their study area.

What types of unintentional injuries kill our children? Do infants die of the same types of injuries? A systematic review

The objective of this study was to review mortality from external causes (accidental injury) in children and adolescents in systematically selected journals. This was a systematic review of the literature on mortality from accidental injury in children and adolescents. We searched the Pubrvled, Latin-American and Caribbean Health Sciences and Excerpta Medica databases for articles published between July of 2001 and June of 2011. National data from official agencies, retrieved by manual searches, were also reviewed. We reviewed 15 journal articles, the 2011 edition of a National Safety Council publication and 2010 statistical data from the Brazilian National Ministry of Health Mortality Database. Most published data were related to high-income countries. Mortality from accidental injury was highest among children less than 1 year of age. Accidental threats to breathing (non-drowning threats) constituted the leading cause of death among this age group in the published articles. Across the pediatric age group in the surveyed studies, traffic accidents were the leading cause of death, followed by accidental drowning and submersion. Traffic accidents constitute the leading external cause of accidental death among children in the countries understudy. However, infants were vulnerable to external causes, particularly to accidental non-drowning threats to breathing, and this age group had the highest mortality rates for external causes. Actions to reduce such events are suggested. Further studies investigating the occurrence of accidental deaths in low-income countries are needed to improve the understanding of these preventable events.

Permissive hypotension does not reduce regional organ perfusion compared to normotensive resuscitation: animal study with fluorescent microspheres

Introduction

The objective of this study was to investigate regional organ perfusion acutely following uncontrolled hemorrhage in an animal model that simulates a penetrating vascular injury and accounts for prehospital times in urban trauma. We set forth to determine if hypotensive resuscitation (permissive hypotension) would result in equivalent organ perfusion compared to normotensive resuscitation.

Methods

Twenty four (n=24) male rats randomized to 4 groups: Sham, No Fluid (NF), Permissive Hypotension (PH) (60% of baseline mean arterial pressure - MAP), Normotensive Resuscitation (NBP). Uncontrolled hemorrhage caused by a standardised injury to the abdominal aorta; MAP was monitored continuously and lactated Ringer’s was infused. Fluorimeter readings of regional blood flow of the brain, heart, lung, kidney, liver, and bowel were obtained at baseline and 85 minutes after hemorrhage, as well as, cardiac output, lactic acid, and laboratory tests; intra-abdominal blood loss was assessed. Analysis of variance was used for comparison.

Results

Intra-abdominal blood loss was higher in NBP group, as well as, lower hematocrit and hemoglobin levels. No statistical differences in perfusion of any organ between PH and NBP groups. No statistical difference in cardiac output between PH and NBP groups, as well as, in lactic acid levels between PH and NBP. NF group had significantly higher lactic acidosis and had significantly lower organ perfusion.

Conclusions

Hypotensive resuscitation causes less intra-abdominal bleeding than normotensive resuscitation and concurrently maintains equivalent organ perfusion. No fluid resuscitation reduces intra-abdominal bleeding but also significantly reduces organ perfusion.

Overview of the shenzhen emergency medical service call pattern

BACKGROUND

In Shenzhen, the Emergency Medical Service (EMS) system has been in service since 1997. This study aims to examine the operation of Shenzhen 120 EMS center and to identify the reasons of calling EMS.

METHODS

In this retrospective quantitative descriptive study, the data from the Shenzhen 120 EMS registry in 2011 were analyzed.

RESULTS

Shenzhen 120 EMS center is a communication command center. When the number of 120 are dialed, it is forwarded to the closest appropriate hospital for ambulance dispatch. In 2011, the Shenzhen 120 EMS center received 153 160 ambulance calls, with an average of 420 calls per day. Calling emergency services was mainly due to traffic accidents. Trauma and other acute diseases constituted a majority of ambulance transports. The adult patients aged 15-60 years are the principal users of EMS. There are no recognized 'paramedic' doctors and nurses. The pre-hospital emergency service is under the operation of emergency departments of hospitals. Shenzhen at present does not have specialized pre-hospital training for doctors and nurses in post-trauma management. Moreover, specialized pre-hospital training, financial support, and public health education on proper use of EMS should be emphasized.

CONCLUSION

The Shenzhen 120 EMS center has its own epidemiology characteristics. Traumatic injury and traffic accident are the main reasons for calling ambulance service. In-depth study emphasizing the distribution and characteristics of trauma patients is crucial to the future development of EMS.

Trauma research in low- and middle-income countries is urgently needed to strengthen the chain of survival

Trauma is a major - and increasing - cause of death, especially in low- and middle income countries. In all countries rural areas are especially hard hit, and the distribution of physicians is skewed towards cities. To reduce avoidable deaths from injury all links in the chain of survival after trauma needs strengthening. Prioritizing in each country should be done by local researchers, but little research on injuries emerges from low- and middle income countries. Researchers in these countries need support and collaboration from their peers in industrialized countries. This partnership will be of mutual benefice.

An investigation into the cost, coverage and activities of Helicopter Emergency Medical Services in the state of New South Wales, Australia

BACKGROUND AND CONTEXT

Helicopter Emergency Medical Services (HEMS) have been incorporated into modern health systems for their speed and coverage. In the state of New South Wales (NSW), nine HEMS operate from various locations around the state and currently there is no clear picture of their resource implications. The aim of this study was to assess the cost of HEMS in NSW and investigate the factors linked with the variation in the costs, coverage and activities of HEMS.

METHODS

We undertook a survey of HEMS costs, structures and operations in NSW for the 2008/2009 financial year. Costs were estimated from annual reports and contractual agreements. Data related to the structure and operation of services was obtained by face-to-face interviews, from operational data extracted from individual HEMS, from the NSW Ambulance Computer Aided Despatch system and from the Aeromedical Operations Centre database. In order to estimate population coverage for each HEMS, we used GIS mapping techniques with Australian Bureau of Statistics census information.

RESULTS

Across HEMS, cost per mission estimates ranged between $9300 and $19,000 and cost per engine hour estimates ranged between $5343 and $15,743. Regarding structural aspects, six HEMS were run by charities or not-for-profit companies (with partial government funding) and three HEMS were run (and fully funded) by the state government through NSW Ambulance. Two HEMS operated as 'hub' services in conjunction with three associated 'satellite' services and in contrast, four services operated independently. Variation also existed between the HEMS in the type of helicopter used, the clinical staffing and the hours of operation. The majority of services undertook both primary scene responses and secondary inter-facility transfers, although the proportion of each type of transport contributing to total operations varied across the services.

INTERPRETATION

This investigation highlighted the cost of HEMS operations in NSW which in total equated to over $50 million per annum. Across services, we found large variation in the cost estimates which was underscored by variation in the structure and operations of HEMS.

Pre-hospital trauma care resources for road traffic injuries in a middle-income country--a province based study on need and access in Iran

BACKGROUND

Access to pre-hospital trauma care can help minimize many of traffic related mortality and morbidity in low- and middle-income countries with high rate of traffic deaths such as Iran. The aim of this study was to assess if the distribution of pre-hospital trauma care facilities reflect the burden of road traffic injury and mortality in different provinces in Iran.

METHODS

This national cross-sectional study is based on ecological data on road traffic mortality (RTM), road traffic injuries (RTIs) and pre-hospital trauma facilities for all 30 provinces in Iran in 2006. Lorenz curves and Gini coefficients were used to describe the distributions of RTM/RTIs and pre-hospital trauma care facilities across provinces. Spearman rank-order correlation was performed to assess the relationship between RTM/RTI and pre-hospital trauma care facilities.

RESULTS

RTM and RTIs as well as pre-hospital trauma care facilities were distributed unequally between different provinces. There was no significant association between the rate of RTM and RTIs and the number of pre-hospital trauma care facilities across the country.

CONCLUSIONS

The distribution of pre-hospital trauma care facilities does not reflect the needs in terms of RTM and RTIs for different provinces. These results suggest that traffic related mortality and morbidity could be reduced if the needs in terms of RTM and RTIs were taken into consideration when distributing pre-hospital trauma care facilities between the provinces.

Current state and future perspectives of trauma care system in mainland China

OBJECTIVE

To investigate the current state of trauma care in mainland China, and to propose possible future suggestions for the development of the trauma care system in mainland China.

METHOD

An extensive Medline/PubMed search on the topic of trauma care or trauma care system was conducted. Publications in Chinese that could best describe the state of trauma care in China were also included. In addition, two meetings were held by Group for Trauma Emergency Care and Multiple Injuries, Trauma Society of Chinese Medical Association to discuss the development and perspectives of trauma care system in mainland China. Important conclusions from the two meetings were included in this publication.

RESULTS

Trauma has become an increasing public health problem in mainland China in association with the rapid growth of the economy over the past 30 years. Although great progress has been made in regards to the care of the injured, there is still no government agency dedicated to deal with trauma-related issues, or a national trauma care system operating on the Chinese mainland. Various trauma prevention measures have been taken, but with little effect. Funds contributed to trauma-related research has increased in recent years and promoted rapid development in this field, but further improvement in research is needed. However, many groups such as the Trauma Society of the Chinese Medical Association have continued to explore mechanisms for the treatment of trauma patients and have developed various types of regional trauma care systems, resulting in improved trauma care and a better outcome for the injured.

CONCLUSIONS

Although great progress has been made in trauma care in mainland China, there are many failings. To improve trauma care in China, the establishment of a sophisticated trauma system and various enhancements on trauma prevention are urgently required.

Prehospital ultrasound as the evolution of the Franco-German model of prehospital EMS

Purpose

To evaluate, throughout model analysis and evaluation of existing literature and personal experience, which can be the benefits of routine performance of prehospital ultrasound in the different models of prehospital emergency medical service.

Methods

The existing literature was reviewed.

Conclusions

The ultrasound can be a very valuable asset in both the Anglo-American and the Franco-German models. In the latter, however, its role is further emphasized since US-enhanced on-spot early diagnosis performed by the physician can be beneficial to the whole system and not just the single patient.

Ketamine as an analgesic in the pre-hospital setting: a systematic review

BACKGROUND

Pain is a common presenting complaint and there is considerable debate regarding the best practice for analgesia in the pre-hospital environment for trauma patients with severe pain.

METHODS

A review of the literature was conducted using a number of electronic medical literature databases from their earliest record to the latest available at the time the search was conducted (May 2010). Medical Subject Headings, keywords and a pre-hospital search filter were used to yield relevant literature.

RESULTS

The search strategy yielded a total of 837 references. Seven hundred and fifty of these references were excluded as they did not meet the inclusion criteria. Of the 87 articles short listed for abstract or full-text review, six reported on ketamine use as an analgesic agent in the pre-hospital setting. Two papers were prospective randomized-controlled trials, and the number of patients included in the studies ranged from 4 to 164. Three studies aimed to report on the effectiveness of ketamine for pain intensity reduction; two concluded that ketamine provided safe and effective pain relief and one reported that ketamine reduced the amount of morphine required but was not associated with a reduction in pain intensity. One study identified a significantly higher prevalence of adverse effects following ketamine administration. The other studies reported no significant side effects and concluded that ketamine was safe.

CONCLUSION

Ketamine is a safe and effective analgesic agent. The addition of ketamine as an analgesic agent may improve the management of patients presenting with acute traumatic pain in the pre-hospital setting.

Barriers and facilitators to provide effective pre-hospital trauma care for road traffic injury victims in Iran: a grounded theory approach

Background

Road traffic injuries are a major global public health problem. Improvements in pre-hospital trauma care can help minimize mortality and morbidity from road traffic injuries (RTIs) worldwide, particularly in low- and middle-income countries (LMICs) with a high rate of RTIs such as Iran. The current study aimed to explore pre-hospital trauma care process for RTI victims in Iran and to identify potential areas for improvements based on the experience and perception of pre-hospital trauma care professionals.

Methods

A qualitative study design using a grounded theory approach was selected. The data, collected via in-depth interviews with 15 pre-hospital trauma care professionals, were analyzed using the constant comparative method.

Results

Seven categories emerged to describe the factors that hinder or facilitate an effective pre-hospital trauma care process: (1) administration and organization, (2) staff qualifications and competences, (3) availability and distribution of resources, (4) communication and transportation, (5) involved organizations, (6) laypeople and (7) infrastructure. The core category that emerged from the other categories was defined as "interaction and common understanding". Moreover, a conceptual model was developed based on the categories.

Conclusions

Improving the interaction within the current pre-hospital trauma care system and building a common understanding of the role of the Emergency Medical Services (EMS) emerged as key issues in the development of an effective pre-hospital trauma care process.

Physician medical direction and clinical performance at an established emergency medical services system

OBJECTIVE

Few developed emergency medical services (EMS) systems operate without dedicated medical direction. We describe the experience of Hamad Medical Corporation (HMC) EMS, which in 2007 first engaged an EMS medical director to develop and implement medical direction and quality assurance programs. We report subsequent changes to system performance over time.

METHODS

Over one year, changes to the service's clinical infrastructure were made: Policies were revised, paramedic scopes of practice were adjusted, evidence-based clinical protocols were developed, and skills maintenance and education programs were implemented. Credentialing, physician chart auditing, clinical remediation, and online medical command/hospital notification systems were introduced.

RESULTS

Following these interventions, we report associated improvements to key indicators: Chart reviews revealed significant improvements in clinical quality. A comparison of pre- and post-intervention audited charts reveals a decrease in cases requiring remediation (11% to 5%, odds ratio [OR] 0.43 [95% confidence interval (CI) 0.20-0.85], p = 0.01). The proportion of charts rated as clinically acceptable rose from 48% to 84% (OR 6 [95% CI 3.9-9.1], p < 0.001). The proportion of misplaced endotracheal tubes fell (3.8% baseline to 0.6%, OR 0.16 [95% CI 0.004-1.06], (exact) p = 0.05), corresponding to improved adherence to an airway placement policy mandating use of airway confirmation devices and securing devices (0.7% compliance to 98%, OR 714 [95% CI 64-29,334], (exact) p < 0.001). Intravenous catheter insertion in unstable cases increased from 67% of cases to 92% (OR 1.31 [95% CI 1.09-1.71], p = 0.004). EMS administration of aspirin to patients with suspected ischemic chest pain improved from 2% to 77% (OR 178 [95% CI 35-1,604], p < 0.001).

CONCLUSIONS

We suggest that implementation of a physician medical direction is associated with improved clinical indicators and overall quality of care at an established EMS system.

Global differences in causes, management, and survival after severe trauma: the recombinant activated factor VII phase 3 trauma trial

BACKGROUND

Little is known about international variation in mortality after severe trauma. This study examines variation in mortality, injury severity, and case management among countries from a recent prospective multinational trauma trial.

METHODS

This trauma trial was a prospective, randomized, double-blinded, multicenter comparison of recombinant activated factor VII versus placebo in severely injured bleeding trauma patients. Differences in baseline patient characteristics, case management, and clinical outcomes were examined for the 11 countries recruiting most patients. Between-country differences in mortality were examined using regression analysis adjusting for case mix and case management differences. Global predictors of mortality were also identified using multivariate regression analysis.

RESULTS

Significant differences were observed between countries in unadjusted mortality rates at 24 hours (p = 0.025) and 90 days (p < 0.0001). When adjusting for differences in case mix and case management, the between country differences in mortality at 24 hours and 90 days remained significant. Consistent independent predictors of 24-hour, 24-hour to 90-day, and 90-day mortality were admission lactate >or=5 mmol/L (odds ratio: 9.06, 3.56, and 5.39, respectively) and adherence to clinical management guidelines (odds ratio: 4.92, 5.90, and 3.26, respectively). On average, the damage control surgery guideline was less well adhered to than the RBC transfusion and ventilator guidelines. There was statistically significant variation between countries with respect to adherence to the RBC transfusion guideline.

CONCLUSIONS

Considering international variation in mortality when designing or interpreting results from multinational trauma studies is important. Significant differences in mortality persisted between patients from different countries after case mix and case management adjustment. Adherence to clinical guidelines was associated with improved survival. Stratification, case mix adjustment, and use of guidelines on damage control surgery, transfusion, and ventilation may mitigate country-driven variation in mortality.

Pre-hospital and in-hospital parameters and outcomes in patients with traumatic brain injury: a comparison between German and Australian trauma registries

INTRODUCTION

In Germany, physician-operated emergency medical services (EMS) manage most pre-hospital trauma care. Australia uses a different EMS system, deploying highly trained paramedics for road and air transport of trauma patients. The effect of these different systems on secondary insults to traumatic brain injury (TBI) patients is unclear. There is conflicting evidence regarding which system is preferable. To add to the body of evidence, we compared the profile of injury, pre-hospital management and outcomes of TBI patients from both populations.

METHODS

Cases aged > or = 16 years, with AIS head > or = 3, AIS other body parts < or = 3, recorded in the Victorian State Trauma Registry (VSTR) and Trauma Registry of the German Society of Trauma Surgery (TR-DGU) from 2002 to 2007 were compared.

RESULTS

10,183 cases (5665 German, 4518 Australian) were included. No difference in sex or median age was observed. There were major between-registry differences in type of injury, trauma circumstance, intent and severity of injury. German cases sustained more serious injury and received more pre-hospital interventions. Mortality was significantly higher amongst German patients even when adjusted for demographics, injury severity and in- and pre-hospital parameters. German patients had a longer hospital and ICU stay.

CONCLUSION

There were clear differences in injury characteristics and outcomes in TBI patients between Germany and Australia. As differences in coding, data collection and patient selection are evident, firm conclusions regarding the contribution of variations in pre-hospital care are not possible. The differences in outcome deserve further exploration in prospective studies.

Trauma systems and early management of severe injuries in Scandinavia: review of the current state

INTRODUCTION

Scandinavian countries face common challenges in trauma care. It has been suggested that Scandinavian trauma system development is immature compared to that of other regions. We wanted to assess the current status of Scandinavian trauma management and system development.

METHODS

An extensive search of the Medline/Pubmed, EMBASE and SweMed+ databases was conducted. Wide coverage was prioritized over systematic search strategies. Scandinavian publications from the last decade pertaining to trauma epidemiology, trauma systems and early trauma management were included.

RESULTS

The incidence of severe injury ranged from 30 to 52 per 100,000 inhabitants annually, with about 90% due to blunt trauma. Parts of Scandinavia are sparsely populated with long pre-hospital distances. In accordance with other European countries, pre-hospital physicians are widely employed and studies indicate that this practice imparts a survival benefit to trauma patients. More than 200 Scandinavian hospitals receive injured patients, increasingly via multidisciplinary trauma teams. Challenges remain concerning pre-hospital identification of the severely injured. Improved triage allows for a better match between patient needs and the level of resources available. Trauma management is threatened by the increasing sub-specialisation of professions and institutions. Scandinavian research is leading the development of team- and simulation-based trauma training. Several pan-Scandinavian efforts have facilitated research and provided guidelines for clinical management.

CONCLUSION

Scandinavian trauma research is characterised by an active collaboration across countries. The current challenges require a focus on the role of traumatology within an increasingly fragmented health care system. Regional networks of predictable and accountable pre- and in-hospital resources are needed for efficient trauma systems. Successful development requires both novel research and scientific assessment of imported principles of trauma care.

[Time intervals during and after emergency room treatment. An analysis using the trauma register of the German Society for Trauma Surgery]

BACKGROUND

The prognosis of severely injured patients depends on a rapid diagnosis and early initiation of therapeutic procedures.

MATERIAL AND METHODS

To that end a total of 6,927 prospectively documented severely injured patients with an Injury Severity Score (ISS) > or =16 from the Trauma Registry of the German Trauma Society (DGU, 2002-2007) were analyzed with respect to time intervals during emergency trauma treatment.

RESULTS

In cases of indicated emergency surgery the average +/-time in the emergency department was 42+/-34 min, in cases of early surgery 75+/-41 min and in cases of transfer to the intensive care unit (ICU) 83+/-43 min, respectively. The time from the last diagnostic procedure until the end of emergency treatment was 12 min (emergency surgery), 26 min (early surgery) and 32 min (ICU), respectively. Level I (78 min) and level II (72 min) trauma centres showed similar mean times in the emergency department while level III trauma centres had a mean time of 86 min. According to this analysis no general correlation between shorter duration of emergency trauma care and reduced mortality could be observed.

CONCLUSION

The duration of time intervals depends on injury severity, treatment after completion of emergency trauma care and the level of the trauma centre. Time management in emergency trauma care can potentially be optimized after completion of the last diagnostic procedure in the emergency room.

How comparable is so-called standard fracture fixation with an identical implant? A prospective experience with the antegrade femoral nail in South Africa and Europe

BACKGROUND

The utilisation and consequences of standardised operative procedures may importantly differ between different healthcare systems. This is the first investigation comparing the treatment and outcome of femoral shaft fractures stabilised with an identical implant between trauma centres in 2 continents (Europe, EU and South Africa, SA).

METHODS

Following standardised introduction of the technique, the prospective, observational multicentre study enrolled 175 patients who underwent intramedullary fracture fixation using the antegrade femoral nail (AFN) for femoral shaft fractures. Eleven EU hospitals recruited 86 patients and 1 SA centre 89 patients in the study period. Comparison of epidemiologic data, operative characteristics as well as subjective (e.g., pain, SF-36) and objective (e.g., X-ray, range of motion [ROM]) 3-month and 1-year outcomes were performed (p<0.05).

RESULTS

Compared to EU centres, several significant differences were observed in SA: (1) on average, patients operated on were younger, had less concomitant diseases and had more severe open fractures; (2) operative stabilisation was more often undertaken by young, unsupervised residents, with shorter operating and intraoperative fluoroscopy times; (3) mean hospital stay was shorter, with less recorded complications, but a higher loss to follow-up rate. Non- or malunion rates and subjective outcomes were similar for both groups, with the physical component of the SF-36 at the 1-year follow-up not fully restoring to baseline values.

CONCLUSIONS

Our investigation demonstrates the importance of several major differences between 2 different regions of the world in the treatment of femoral shaft fractures, despite involving only high level trauma centres and using an identical implant. The intercontinental comparison of results from clinical studies should be interpreted very carefully considering the heterogeneity of populations and clinical settings.

Permissive hypotension and desmopressin enhance clot formation

BACKGROUND

Experimental studies of uncontrolled hemorrhage demonstrated that permissive hypotension (PH) reduces blood loss, but its effect on clot formation remains unexplored. Desmopressin (DDAVP) enhances platelet adhesion promoting stronger clots. We hypothesized PH and DDAVP have additive effects and reduce bleeding in uncontrolled hemorrhage.

METHODS

Rabbits (n = 42) randomized as follows: sham; normal blood pressure (NBP) resuscitation; PH resuscitation-60% baseline mean arterial pressure; NBP plus DDAVP 1 hour before (DDAVP NBP) or 15 minutes after beginning of shock (DDAVP T1 NBP); and PH plus DDAVP 1 hour before (DDAVP PH) or 15 minutes after beginning of shock (DDAVP T1 PH). Fluid resuscitation started 15 minutes after aortic injury and ended at 85 minutes. Intraabdominal blood loss was calculated, aortic clot sent for electron microscopy. Activated partial thromboplastin time, platelet count, thromboelastometry, arterial blood gases, and complete blood count were performed at baseline and 85 minutes. Analysis of variance was used for comparison.

RESULTS

NBP received more fluid volume and had greater intraabdominal blood loss. DDAVP, when administered preshock, significantly reduced blood loss in NBP and fluid requirement when given postshock. Platelets, arterial blood gas, complete blood count, and activated partial thromboplastin time were similar at 85 minutes. NBP delayed clot formation and worsened thrombodynamic potential on thromboelastometry, whereas PH and DDAVP improved. Electron microscopy showed lack of fibrin on NBP clots, whereas DDAVP and PH clots displayed exuberant fibrin/platelet aggregates. DDAVP NBP presented intermediate clots.

CONCLUSION

PH reduced bleeding and improved hemostasis compared with normotensive resuscitation. DDAVP given preshock exerted similar effects with normotensive resuscitation.

Predictors of survival from out-of-hospital cardiac arrest: a systematic review and meta-analysis

BACKGROUND

Prior studies have identified key predictors of out-of-hospital cardiac arrest (OHCA), but differences exist in the magnitude of these findings. In this meta-analysis, we evaluated the strength of associations between OHCA and key factors (event witnessed by a bystander or emergency medical services [EMS], provision of bystander cardiopulmonary resuscitation [CPR], initial cardiac rhythm, or the return of spontaneous circulation). We also examined trends in OHCA survival over time.

METHODS AND RESULTS

An electronic search of PubMed, EMBASE, Web of Science, CINAHL, Cochrane DSR, DARE, ACP Journal Club, and CCTR was conducted (January 1, 1950 to August 21, 2008) for studies reporting OHCA of presumed cardiac etiology in adults. Data were extracted from 79 studies involving 142 740 patients. The pooled survival rate to hospital admission was 23.8% (95% CI, 21.1 to 26.6) and to hospital discharge was 7.6% (95% CI, 6.7 to 8.4). Stratified by baseline rates, survival to hospital discharge was more likely among those: witnessed by a bystander (6.4% to 13.5%), witnessed by EMS (4.9% to 18.2%), who received bystander CPR (3.9% to 16.1%), were found in ventricular fibrillation/ventricular tachycardia (14.8% to 23.0%), or achieved return of spontaneous circulation (15.5% to 33.6%). Although 53% (95% CI, 45.0% to 59.9%) of events were witnessed by a bystander, only 32% (95% CI, 26.7% to 37.8%) received bystander CPR. The number needed to treat to save 1 life ranged from 16 to 23 for EMS-witnessed arrests, 17 to 71 for bystander-witnessed, and 24 to 36 for those receiving bystander CPR, depending on baseline survival rates. The aggregate survival rate of OHCA (7.6%) has not significantly changed in almost 3 decades.

CONCLUSIONS

Overall survival from OHCA has been stable for almost 30 years, as have the strong associations between key predictors and survival. Because most OHCA events are witnessed, efforts to improve survival should focus on prompt delivery of interventions of known effectiveness by those who witness the event.

Injury deaths of US citizens abroad: new data source, old travel problem

BACKGROUND

Global travel continues to increase, including among US citizens. The global burden of injuries and violence, accounting for approximately 5 million deaths worldwide in 2000, is also growing. Travelers often experience heightened risk for this biosocial disease burden. This study seeks to further describe and improve our understanding of the variable risk of travel-related injury and death.

METHODS

Information on US civilian citizen deaths from injury while abroad was obtained from the US Department of State Web site. This information was categorized into regional and causal groupings. The groupings were compared to each other and to injury deaths among citizens in their native countries.

RESULTS

From 2004 to 2006, there were 2,361 deaths of US citizens overseas due to injury. Of these US citizen injury deaths, 50.4% occurred in the Americas region. Almost 40% (37.8%) of US citizen injury deaths in the low- to middle-income Americas were due to vehicle crashes compared to about half that (18.9%) (proportional mortality ratio [PMR] = 1.72, 95% confidence interval [CI] 1.59-1.62) for low- to middle-income Americas citizen injury deaths. Similar differences between US citizen injury death abroad and the in-country distributions were also found for vehicle crashes in Europe (35.9% vs 16.5%, PMR = 2.17, 95% CI 1.78-2.64; p < 0.0005), for drowning deaths in the Americas (13.1% vs 4.6%, PMR = 2.67, 95% CI 2.29-3.11) and many island nations (63.5% vs 3.5%, PMR = 11.38, 95% CI 8.17-15.84), and for homicides in the low- to middle-income European countries (16.9% vs 10.5%, PMR = 1.52, 95% CI .90-2.57).

CONCLUSIONS

US citizens should be aware of regional variation of injury deaths in foreign countries, especially for motor vehicle crashes, drowning, and violence. Improved knowledge of regional variations of injury death and risk for travelers can further inform travelers and the development of evidence-based prevention programs and policies. The State Department Web site is a new data source that furthers our understanding of this challenging travel-related health issue.

Older people's use of pre-hospital emergency medical services in Izmir, Turkey

The aim of this study is to determine the use of pre-hospital emergency medical services (EMS) in elderly people aged 65 years and over in Izmir, Turkey. In this descriptive study, older patients admitted to pre-hospital EMS of Izmir Province Health Directorate between 2004 and 2005 years was evaluated through the review of Emergency Call Registry Forms. The study data included socioeconomic characteristics, reasons of calling, distribution of calling times in the day, distribution of ambulance callers and preclinical diagnosis. A total of 34% of the subjects admitted to pre-hospital EMS were 65 years old and over. The rate of the use of ambulance services was 68.9/1000 population/year. The rate of pre-hospital EMS use for older persons living in urban areas was significantly higher than that of those living in rural areas. The most frequent pre-hospital EMS caller were persons in family (70.7%), and utilization of ambulance services was the highest in winter. Medically related incidents accounted for 89.1% of all emergency ambulance calls and cardiovascular diseases accounted for most common cause (32.6%) of calls. The utilization rate of pre-hospital EMS among older persons was approximately four times higher than that of the younger age groups.

A systematic review of controlled studies: do physicians increase survival with prehospital treatment?

Background

The scientific evidence of a beneficial effect of physicians in prehospital treatment is scarce. The objective of this systematic review of controlled studies was to examine whether physicians, as opposed to paramedical personnel, increase patient survival in prehospital treatment and if so, to identify the patient groups that gain benefit.

Methods

A systematic review of studies published in the databases PubMed, EMBASE and Cochrane from January 1, 1990 to November 24, 2008. Controlled studies comparing patient survival with prehospital physician treatment vs. treatment by paramedical personnel in trauma patients or patients with any acute illness were included.

Results

We identified 1.359 studies of which 26 met our inclusion criteria. In nine of 19 studies including between 25 and 14.702 trauma patients in the intervention group, physician treatment increased survival compared to paramedical treatment. In four of five studies including between nine and 85 patients with out of hospital cardiac arrest, physician treatment increased survival. Only two studies including 211 and 2.869 patients examined unselected, broader patient groups. Overall, they demonstrated no survival difference between physician and paramedical treatment but one found increased survival with physician treatment in subgroups of patients with acute myocardial infarction and respiratory diseases.

Conclusion

Our systematic review revealed only few controlled studies of variable quality and strength examining survival with prehospital physician treatment. Increased survival with physician treatment was found in trauma and, based on more limited evidence, cardiac arrest. Indications of increased survival were found in respiratory diseases and acute myocardial infarction. Many conditions seen in the prehospital setting remain unexamined.

Innovations in osteosynthesis and fracture care

Over the years giant steps have been made in the evolution of fracture fixation and the overall clinical care of patients. Better understanding of the physiological response to injury, bone biology, biomechanics and implants has led to early mobilisation of patients. A significant reduction in complications during the pre-operative and post-operative phases has also been observed, producing better functional results. A number of innovations have contributed to these improved outcomes and this article reports on the advances made in osteosynthesis and fracture care.

Paramedic versus emergency physician emergency medical service: role of the anaesthesiologist and the European versus the Anglo-American concept

PURPOSE OF REVIEW

Much controversy exists about who can provide the best medical care for critically ill patients in the prehospital setting. The Anglo-American concept is on the whole to provide well trained paramedics to fulfil this task, whereas in some European countries emergency medical service physicians, particularly anaesthesiologists, are responsible for the safety of these patients.

RECENT FINDINGS

Currently there are no convincing level I studies showing that an emergency physician-based emergency medical service leads to a decrease in overall mortality or morbidity of prehospital treated patients, but many methodical, legal and ethical issues make such studies difficult. Looking at specific aspects of prehospital care, differences in short-term survival and outcome have been reported when patients require cardiopulmonary resuscitation, advanced airway management or other invasive procedures, well directed fluid management and pharmacotherapy as well as fast diagnostic-based decisions.

SUMMARY

Evidence suggests that some critically ill patients benefit from the care provided by an emergency physician-based emergency medical service, but further studies are needed to identify the characteristics and early recognition of these patients.