Strengthening Prehospital Trauma Care in the Absence of Formal Emergency Medical Services

Abstract

The article by Jayaraman, Mbweijano, Lipnick et al. represents an important contribution to the literature because it addresses one of the most significant and difficult issues in care of the injured [1]. This is the issue of how to improve prehospital trauma care services in areas of lowand middle-income countries that are beyond the reach of any formal emergency medical services (EMS). This issue is of great significance for several reasons: Most of the injured who die do so in the field, before there is any chance of hospital care. In lowand middle-income countries the proportion of prehospital deaths is much higher than in high-income countries. For example, one study showed that of all trauma patients who die, 81% die in the field in a low-income setting (Ghana) compared with 72% in a middle-income setting (Mexico), and 59% in a highincome setting (USA). This difference in prehospital deaths is a major contributor to the overall higher case fatality rates for severely injured persons in lowand middleincome countries. Furthermore, it has been roughly estimated that some 50–75% of the world’s people live in areas with no access to formal EMS [2, 3]. In brief, this paper is of great relevance to the field of trauma care, as it addresses the situation in which many— possibly most—fatal injuries occur: in the field, in a lowor middle-income country, in an area with no formal EMS. This scenario has scarcely been addressed by the field of trauma care research, thus far. Given these factors, the question then arises of how to improve access to prehospital trauma care in the setting of lowand middle-income countries, especially in areas where no formal EMS currently exists. The World Health Organisation (WHO) publication Prehospital Trauma Care Systems gives guidance on two complementary approaches, designated tier 1 and tier 2 care. Tier 1 implies care by first responders, often not as part of a formal system, whereas tier 2 implies formal EMS, such as with an ambulance service [4]. There is evidence from several locations worldwide that each approach may be useful, depending on the circumstances. One study from Brazil has documented the effects of a new ambulance service (i.e., tier 2) started where none had previously existed: The mortality rate among victims of motor vehicle crashes decreased from 7.1% (before) to 5.9% (after) [5]. However, starting new formal EMS should be approached with caution, given the potential high cost. An economic analysis from Kuala Lumpur, Malaysia, suggested that upgrading that city’s existing basic EMS to a high-income model would cost $2.5 million per year, with only an additional 7 lives per year saved [6]. Whether one agrees with the specifics of this economic analysis or not, certainly the caution these authors urge is warranted. Hence, there is a need not only to consider the creation of new formal EMS, but also alternatives that will increase local access to basic first aid measures (i.e., tier 1 care). In some cases these might be considered as adjuncts to formal EMS, allowing ambulance services to extend their reach through networks of first responders. In other cases, these might be standalone efforts, especially in circumstances where formal EMS would be impractical or too costly. Often, these efforts to increase access to basic first aid The author is a staff member of the World Health Organization. He alone is responsible for the views expressed in this publication and they do not necessarily represent the decisions or policies of the World Health Organization.