Formal Emergency Medical Services Research Articles

The emergency burden in low and middle-income countries

Injuries are the greatest single cause of surgical disease globally, disproportionately affecting low and middle-income countries and representing 10% of global mortality and 32% greater annual mortality than HIV/AIDS, tuberculosis, and malaria combined. Road traffic injuries are the single greatest contributor to the global injury burden and the leading cause of death for young people aged 5 to 29 years. In May 2023, the 76th World Health Assembly resolved that emergency, critical, and operative care services are an integral part of a comprehensive national primary health care approach and foundational for health systems to effectively address emergencies. However, robust trauma systems and emergency medical services are lacking in low and middle-income countries to adequately address the prehospital injury burden in systematic and financially sustainable approaches, despite the disproportionate burden faced. Replicating formal Tier 2 emergency medical services (staffed by professional emergency responders within well-defined jurisdictions using dedicated vehicles and equipment) from high-income countries has failed, and the World Health Organization recommends Tier 1 systems (community bystander-driven prehospital care by provided by lay first responders) as the first step toward formal emergency medical services in these same settings. The Global Prehospital Consortium has identified 7 priority areas as a framework for future emergency medical services development, forming the basis for the remaining articles in this series, spanning infrastructure and operations, communication, education/training, impact evaluation, financing, governance/legal, and transportation/equipment.

Emergency medical dispatch technologies: Addressing communication challenges and coordinating emergency response in low and middle-income countries

A majority of emergency response in low and middle-income countries (LMICs) without formal emergency medical services (EMS) rely on uncoordinated layperson first responders (LFRs) to respond to emergencies using readily available mobile phones and private transport. Although formally trained LFRs are an important foundation for nascent emergency medical services (EMS) development, without coordination by standardized emergency medical dispatch (EMD) systems, LFR response is limited to witnessed emergencies, which provides significant but incomplete coverage. After training and equipping LFRs, EMD implementation using telecommunications technologies is the next step in formal EMS development and is essential to coordinate response, given the impact of timely prehospital response, intervention, and transportation on reducing morbidity/mortality. In this paper, we describe the current state of dispatch technologies used for emergency response in LMICs, focusing on the role of communication technologies, current approaches, and challenges in communication, and offer potential strategies for future development.

Future directions for emergency medical services development in low- and middle-income countries

The lack of prehospital care access in low- and middle-income countries is one of the greatest unmet needs and, therefore, one of the most urgent priorities in global health. Establishing emergency medical services in low- and middle-income countries poses significant challenges and complexities, requiring solutions tailored to prevailing conditions, informed by needs assessments, and adapted to meet local demands in a culturally appropriate and sustainable manner. In areas without existing emergency medical services, patients must rely on informal networks of untrained bystanders and community members to provide first aid and transport to definitive care. Since 2005, training lay first responders has been recommended by the World Health Organization as the first step toward formal emergency medical services development. However, efforts to formalize lay first responders networks have not expanded with the increasing need for prehospital emergency care in low- and middle-income countries, despite their potential. The rapid expansion of communication technologies like mobile smartphones penetrating resource-limited settings offers effective and inexpensive options for dispatching and coordinating lay first responders that were not previously available. These technologies can also be used for more advanced emergency medical services, obviating expensive communications and dispatch infrastructure. Despite disproportionately bearing the global injury burden, lay first responders frequently lack accurate and comprehensive surveillance data secondary to widespread underreporting, especially for non-fatal events. Lay first responders expand surveillance, which may inform future targeted prevention efforts, assisting in the development of tailored countermeasures suited to local hazards and diseases. Emergency medical services development in low- and middle-income countries involves a strategic approach focused on understanding the unique needs of diverse communities, requiring broad stakeholder involvement to create a sense of ownership to maintain volunteer networks and enhance sustainability. By embracing these relatively low-cost, bottom-up strategies, low- and middle-income countries can develop more accessible, efficient, and community-oriented emergency medical systems, ultimately improving public health outcomes and averting preventable deaths to address the emergency burden.

Leveraging transportation providers to deploy lay first responder (LFR) programs in three sub-Saharan African countries without formal emergency medical services: Evaluating longitudinal impact and cost-effectiveness

IntroductionIn 2019, the World Health Assembly declared emergency care essential to achieve the 2030 Sustainable Development Goals. Few sub-Saharan African (SSA) countries have developed robust approaches to sustainably deliver emergency medical services (EMS) at scale, as high-income country models are financially impractical. Innovative reassessment of EMS delivery in resource-limited settings is necessary as timely emergency care access can substantially reduce mortality. Materials and methodsWe developed the Lay First Responder (LFR) program by training 1,291 pre-existing motorcycle taxi drivers, a predominant form of short-distance transport in sub-Saharan Africa, to provide trauma care and transport for road traffic injuries. Three pilot programs were launched in staggered fashion between 2016 and 2019 in West, Central, and East Africa and a 5.5 h curriculum was iteratively developed to train first responders. Longitudinal data on patient impact (patient demographics, injury characteristics, and treatment rendered), emergency care knowledge acquisition/retention, and social/financial effects of LFR training were collected and pooled across three sites for collective analysis. Novel cost-effectiveness ratios were calculated based on prospective cost data from each site. Previously projected aggregate disability-adjusted life years (DALYs) addressable by LFRs were used to inform cost-effectiveness ratios($USD cost per DALY averted). Cost-effectiveness ratios were then compared against African per capita gross domestic product (GDP), following WHOCHOICE guidelines, which state ratios less than GDP per capita are "very cost-effective." ResultsIn 2,171 total patient encounters across all three pilot sites, LFRs most frequently provided hemorrhage control in 61 % of patient encounters and patient transport by motorcycle in 98.5 %. Median pre-/post-test scores improved by 34.1 percentage points (39.5% vs.73.6 %, p < 0.0001) with significant knowledge retention at six months. 75 % of initial participants remain voluntarily involved 3 years post-course, reporting increased local stature and customer acquisition(income 32.0 % greater than non-trained counterparts). Locally sourced first-aid materials cost $6.54USD/participant. Cost-effectiveness analysis demonstrated cost per DALY averted=$51.65USD. ConclusionLFR training is highly cost-effective according to WHOCHOICE guidelines and expands emergency care access. The LFR program may be an alternative approach to formal ambulance-reliant EMS that are cost-prohibitive in resource-limited, sub-Saharan African settings. A novel social/financial mechanism appears to incentivize long-term voluntary LFR involvement, which may sustain programs in resource-limited settings.

Comparative epidemiology and outcomes among trauma patients transported by private and formal pre-hospital care modes in Kigali, Rwanda

INTRODUCTION: The burden of injuries is high in low- and middle-income countries where pre-hospital systems are being developed to improve acute injury care. This study compares the characteristics and outcomes between trauma patients transported by formal emergency medical services (EMS) and by private transport to the emergency department (ED) of the Centre Hospitalier Universitaire de Kigali (CHUK) in Rwanda.&#x0D; METHODS: This retrospective cohort study analyzed a random sample of trauma patients presenting between 1 August 2015 and 30 July 2016. Descriptive analyses were performed, and differences in outcomes were assessed based on transport modalities via Pearson Chi-Squared or Fisher’s Exact tests.&#x0D; RESULTS: Of the 556 trauma patients analyzed, 87.1% were transported by private transport and the remainder by EMS. The median inpatient length of stay for private transport patients was 7 days (IQR:3-16 days), compared to 9.5 days for EMS patients (IQR:4-18 days) (p=0.301). More EMS-transported patients died in the ED (p=0.005), and more were admitted to the hospital. There was a higher mortality rate among patients admitted to the hospital who arrived by private transport, but the difference was not statistically significant.&#x0D; CONCLUSION: The higher ED death rate among EMS-transported patients and the higher in-hospital death rate among private transport patients suggest that major differences in the two groups may or may not be related to how trauma patients are brought to the ED.

Evaluating feasibility of a novel mobile emergency medical dispatch tool for lay first responder prehospital response coordination in Sierra Leone: A simulation-based study

IntroductionThe global injury burden, driven by road traffic injuries, disproportionately affects low- and middle-income countries, which lack robust emergency medical services (EMS) to address injury. The WHO recommends training lay first responders (LFRs) as the first step toward formal EMS development. Emergency medical dispatch (EMD) systems are the recognized next step but whether small groups of LFRs equipped with mobile dispatch infrastructure can efficiently respond to geographically-dispersed emergencies in a timely fashion and the quality of prehospital care provided is unknown. Materials and methodsWe piloted an EMD system utilizing a mobile phone application in Sierra Leone. Ten LFRs were randomly selected from a pool of 61 highly-active LFRs trained in 2019 and recruited to participate in an emergency simulation-based study. Ten simulation scenarios were created matching proportions of injury conditions across 1,850 previous incidents (June-December 2019). Fifty total simulations were launched in randomized order over 3 months, randomized along 10 km of highway in Makeni. Replicating real-world conditions, highly-active LFR participants were blinded to randomized dispatch timing/scenario to assess response time and skill performance under direct observation with a checklist using standardized patient actors. We used novel cost data tracked during EMD pilot implementation to inform the calculation of a new cost-effectiveness ratio ($USD cost per disability-adjusted life year averted (DALY)) for LFR programs equipped with dispatch, following WHOCHOICE guidelines, which state cost-effectiveness ratios less than gross domestic product (GDP) per capita are considered “very cost-effective.” ResultsMedian total response interval (notification to arrival) was 5 min 39 s (IQR:0:03:51, 0:09:18). LFRs initially trained with a 5-hour curriculum and refresher training provide high-quality prehospital care during simulated emergencies. Median first aid skill checklist completion was 89% (IQR: 78%, 90%). Cost-effectiveness equals $179.02USD per DALY averted per 100,000 people, less than Sierra Leonean GDP per capita ($484.52USD). ConclusionLFRs equipped with mobile dispatch demonstrate appropriate response times and effective basic initial management of simulated emergencies. Training smaller cohorts of highly-active LFRs equipped with mobile dispatch appears highly cost-effective and may be a feasible model to facilitate efficient dispatch to expand emergency coverage while conserving valuable training resources in resource-limited settings.

Post-Crash First Response by Traffic Police in Nepal: A Feasibility Study.

Background: Road traffic injuries are a significant and increasing public health burden in Nepal, but there is no national coverage of regulated and standardized emergency medical service systems. Therefore, this study was designed to develop a first responder trauma training program for the Nepal traffic police and to evaluate the feasibility of its delivery and follow up. Methods: A training needs assessment with traffic-police officers in a single district of Nepal informed the development of a 3-day first-response course which was provided to officers in May 2019. Participants were supplied with a trauma-pack and asked to complete a report form when first-responder skills were used. Knowledge and confidence face-to-face surveys were used before and after training to assess learning, and were repeated at 6 months to assess retention of knowledge. The surveys at 6 months assessed the factors affecting application of first response skills. Results: Most (97%) participants believed giving first-aid was part of their responsibilities and 95% had experience of transporting road crash victims to hospital with a range of injuries. Low levels of first-aid training and variable course content were reported. Knowledge and confidence scores improved post-intervention but were reduced at 6-months. During attendance at 303 road crashes in the 6-months follow-up period, 44% of the participants self-reported using at least one skill from the course; applying them on 92 occasions. Incident report-forms were frequently not completed. Barriers to providing treatment included: the patient already en-route to hospital when police arrived at scene; resistance to providing care from relatives or bystanders; and competing police duties (e.g., traffic management). Conclusions: Delivering a first-response training program for traffic-police in Nepal is feasible. Knowledge was retained and used, and skills were in frequent demand. A study of effectiveness and cost-effectiveness appears warranted to determine if extending the training to other districts can improve outcomes in road traffic injury patients in the absence of formal emergency medical services.

The activities and impacts of a community-based volunteer ambulance service in Cape Town, South Africa.

IntroductionVolunteering yields valuable benefits to communities, yet globally there is limited published data regarding emergency medical volunteering in communities. Hout Bay Volunteer Emergency Medical Service is thought to be the oldest volunteer ambulance service in Cape Town. The objective of this paper is to quantify the contribution of the community service to the Western Cape Government Health: Emergency Medical Service. This paper describes the inputs, key stakeholder relationships, and the impact of COVID-19 on volunteer input and community needs.MethodsElectronic Computer-Aided Dispatch records were used for analysis. Data extracted included detailed information about all recorded incidents between 1 January 2015 to 31 December 2020. Data were analysed in Google Sheets using Pivot Tables and summary statistics.ResultsBetween 2015 and 2020 HBVEMS responded to approximately 12% of all call-outs in the Hout Bay area, which equates to 2187.16 h of operational time spent on calls. This excludes standby time, i.e., time spent waiting to be dispatched. There was an expected noticeable difference between response times for ambulances based within Hout Bay, and those from outside Hout Bay. Despite a decline in average call-out rate during the 2020 Level 5 lockdown, the volunteers were able to do more shifts and thus more calls within the community. Call-outs during 2020 were visualised as a ratio of trauma to medical calls. In this period there were noticeably fewer trauma calls.ConclusionsThere is a growing need for emergency medical care, and volunteer ambulance services can have a meaningful impact on the continent. The findings support the benefit of developing community-based ambulance services, especially in areas that are remote due to distance or topography. The model can be expanded to other communities across the continent. A key factor for success is actively managing stakeholder relationships which include community-based relationships as well as governmental or formal emergency medical services relationships.

Why Bystanders Did Not Perform Cardiopulmonary Resuscitation on Out-of-Hospital Cardiac Arrest Patients: A Multi-Center Study in Hanoi (Vietnam).

The aim of this study was to determine why bystanders did not use formal Emergency Medical Services (EMS) or conduct cardiopulmonary resuscitation (CPR) on the scene for out-of-hospital cardiac arrest (OHCA) patients in Hanoi, Vietnam. This was a prospective, observational study of OHCA patients admitted to five tertiary hospitals in the Hanoi area from June 2018 through January 2019. The data were collected through interviews (using a structured questionnaire) with bystanders. Of the 101 patients, 79% were aged <65 years, 71% were men, 79% were witnessed to collapse, 36% were transported to the hospital by formal EMS, and 16% received bystander CPR at the scene. The most frequently indicated reason for not using EMS by the attendants was "using a private vehicle or taxi is faster" (85%). The reasons bystanders did not conduct CPR at the scene included "not recognizing the ailment as cardiac arrest" (60%), "not knowing how to perform CPR" (33%), and "being afraid of doing harm to patients" (7%). Only seven percent of the bystanders had been trained in CPR. The information revealed in this study provides useful information to indicate what to do to increase EMS use and CPR provision. Spreading awareness and training among community members regarding EMS roles, recognition of cardiac arrest, CPR skills, and dispatcher training to assist bystanders are crucial to improve the outcomes of OHCA patients in Vietnam.

Cost-Effectiveness of Lay First Responders Addressing Road Traffic Injury in Sub-Saharan Africa

To investigate the cost-effectiveness of training lay first responders (LFRs) to address road traffic injury (RTI) in sub-Saharan Africa (SSA) as the first step toward formal emergency medical services (EMS) development. Cost data from five LFR programs launched between 2008 and 2019 in SSA was collected for LFR cost estimation, including three prospective collections from our group. We systematically reviewed literature and projected aggregate disability-adjusted life years (DALYs) from RTI in SSA that are addressable by LFRs to inform cost-effectiveness ratios ($USD cost per DALY averted). Cost-effectiveness ratios were then compared against African per capita gross domestic product (GDP) to determine the cost-effectiveness of LFRs addressing RTIs in SSA, following WHO-CHOICE guidelines, which state cost-effectiveness ratios less than GDP per capita are considered "very cost-effective." Average annual cost per LFR trained across five programs was calculated to be 16.32USD (training=4.04USD, supplies=12.28USD). Following WHO and Disease Control Priorities recommendations for adequate emergency catchment, initial training of 750 LFRs per 100,000 people would cost 12,239.47USD with projected total annual DALYs averted equal to 227.7 per 100,000. Cost per DALY averted would therefore be 53.75USD with appropriate LFR availability, less than sub-Saharan African GDP per capita (1,585.40USD) and the lowest sub-Saharan African GDP per capita (Burundi, 261.20USD). Following WHO-CHOICE guidelines, training LFRs can be a highly cost-effective means to address RTI morbidity and mortality across sub-Saharan Africa. With EMS unavailable for 91.3% of the African population, training LFRs can be an affordable first step toward formal EMS development.

Evaluating a Novel Prehospital Emergency Trauma Care Assessment Tool (PETCAT) for Low- and Middle-Income Countries in Sierra Leone.

WHO recommends training lay first responders (LFRs) as the first step toward formal emergency medical services development, yet no tool exists to evaluate LFR programs. We developed Prehospital Emergency Trauma Care Assessment Tool (PETCAT), a seven-question survey administered to first-line hospital-based healthcare providers, to independently assess LFR prehospital intervention frequency and quality. PETCAT surveys were administered one month pre-LFR program launch (June 2019) in Makeni, Sierra Leone and again 14months post-launch (August 2020). Using a difference-in-differences approach, PETCAT was also administered in a control city (Kenema) with no LFR training intervention during the study period at the same intervals to control for secular trends. PETCAT measured change in both the experimental and control locations. Cronbach's alpha, point bi-serial correlation, and inter-rater reliability using Cohen's Kappa assessed PETCAT reliability. PETCAT administration to 90 first-line, hospital-based healthcare providers found baseline prehospital intervention were rare in Makeni and Kenema prior to LFR program launch (1.2/10 vs. 1.8/10). Fourteen months post-LFR program implementation, PETCAT demonstrated prehospital interventions increased in Makeni with LFRs (5.2/10, p < 0.0001) and not in Kenema (1.2/10) by an adjusted difference of + 4.6 points/10 (p < 0.0001) ("never/rarely" to "half the time"), indicating negligible change due to secular trends. PETCAT demonstrated high reliability (Cronbach's α = 0.93, Cohen's K = 0.62). PETCAT measures changes in rates of prehospital care delivery by LFRs in a resource-limited African setting and may serve as a robust tool for independent EMS quality assessment.

Evaluation of a Lay First Responder Program in Sierra Leone as a Scalable Model for Prehospital Trauma Care

Few countries in Sub-Saharan Africa have robust emergency medical services (EMS). The World Health Organization (WHO) recommends scaling-up lay first responder programs as the first step toward formal EMS development. We trained and equipped 4,529 lay first responders (LFRs) between June-December 2019 in Bombali District, Sierra Leone, with a 5-hour hands-on, contextually-adapted prehospital trauma course to cover 535,000 people. Instructors trained 1,029 LFRs and 50 local trainers in a training-of-trainers (TOT) model, who then trained an additional 3,500 LFRs. A validated, 23-question pre-/post-test measured knowledge improvement, while six- and nine-month follow-up tests measured knowledge retention. Incident reports tracked patient encounters to assess longitudinal impact. Median pre-/post-test scores improved by 43.5 percentage points (34.8% vs. 78.3%, p<0.0001). Knowledge retention was assessed at six months, with median score dropping to 60.9%, while at nine months, median score dropped to 43.5%. Lay first responders participating in courses led by TOT trainers had a pre-/post-test median score improvement of 30.4 percentage points (21.7% vs. 52.2%, p<0.0001). LFRs treated 1,850 patients over six months, most frequently utilizing hemorrhage control skills in 61.2% of encounters (1,133/1,850). The plurality of patients were young adult males (36.8%) and 48.7% of encounters were motorcycle injury-related. A 5-hour first responder course targeting laypeople demonstrates significant emergency care knowledge improvement and retention. By training networks of transportation providers, lay first responder programs represent a robust and scalable prehospital emergency care alternative for low-resource settings.

Developing a Lay First Responder Program in Chad: A 12-Month Follow-Up Evaluation of a Rural Prehospital Emergency Care Program.

The World Health Organization (WHO; Geneva, Switzerland) recommends lay first responder (LFR) programs as a first step toward establishing formal Emergency Medical Services (EMS) in low- and middle-income countries (LMICs) to address injury. There is a scarcity of research investigating LFR program development in predominantly rural settings of LMICs. A pilot LFR program was launched and assessed over 12 months to investigate the feasibility of leveraging pre-existing transportation providers to scale up prehospital emergency care in rural, low-resource settings of LMICs. An LFR program was established in rural Chad to evaluate curriculum efficacy, using a validated 15-question pre-/post-test to measure participant knowledge improvement. Pre-/post-test score distributions were compared using a Wilcoxon Signed-Rank test. For test evaluation, each pre-test question was mapped to its corresponding post-test analog and compared using McNemar's Chi-Squared Test to examine knowledge acquisition on a by-question basis. Longitudinal prehospital care was evaluated with incident reports, while program cost was tracked using a one-way sensitivity analysis. Qualitative follow-up surveys and semi-interviews were conducted at 12 months, with initial participants and randomly sampled motorcycle taxi drivers, and used a constructivist grounded theory approach to understand the factors motivating continued voluntary participation to inform future program continuity. The consolidated criteria for reporting qualitative research (COREQ) checklist was used to guide design, analysis, and reporting the qualitative results. A total of 108 motorcycle taxi participants demonstrated significant knowledge improvement (P <.001) across three of four curricular categories: scene safety, airway and breathing, and bleeding control. Lay first responders treated 71 patients over six months, encountering five deaths, and provided patient transport in 82% of encounters. Lay first responders reported an average confidence score of 8.53/10 (n = 38). In qualitative follow-up surveys and semi-structured interviews, the ability to care for the injured, new knowledge/skills, and the resultant gain in social status and customer acquisition motivated continued involvement as LFRs. Ninety-six percent of untrained, randomly sampled motorcycle taxi drivers reported they would be willing to pay to participate in future training courses. Lay first responder programs appear feasible and cost-effective in rural LMIC settings. Participants demonstrate significant knowledge acquisition, and after 12 months of providing emergency care, report sustained voluntary participation due to social and financial benefits, suggesting sustainability and scalability of LFR programs in low-resource settings.

Current trauma care system in Saudi Arabia: A scoping literature review

BackgroundTrauma is one of the leading causes of death worldwide with millions of people dying each year, particularly in low or middle-income countries. This paper describes and evaluates the current trauma system (TS) in Saudi Arabia (SA). MethodsA scoping literature review was performed, incorporating an extensive search of Medline and Embase databases for refereed literature, as well as a search of grey literature to locate unpublished articles or reports in English or Arabic. All publications were assessed against the World Health Organization (WHO) Trauma System Maturity Index (TSMI) and American College of Surgeon’s (ACS) criteria. ResultsDespite local injury prevention efforts, Motor Vehicle Crashes (MVC) remain the primary cause of injuries in SA. Prehospital trauma care in SA aligns with level III care as described in the WHO TSMI classification system, based on the presence of formal emergency medical services and universal access to care. With respect to the ACS classification, no clear written guidelines, either for field triage or trauma destination protocols such as trauma bypass, were identified in prehospital trauma care. The role of secondary and tertiary facilities in treating trauma patients is unclear, with no clear referral linkages, suggesting a level I to III grading of SA’s trauma care facilities. Currently, there is no national or regional electronic trauma registry, no quality assurance program, and active involvement in research projects related to injuries is limited. ConclusionThe current SA TS has strengths but there are key features missing in comparison to other systems globally. As MVCs remain a leading cause of death/ disability, efforts to reduce the prevalence and impact of MVC burden in SA through development of a stronger national TS are warranted.

Development and implementation of a first responder program in rural Haiti: The involved citizen project

Background: Northeast Haiti lacks comprehensive prehospital emergency medical services (EMS). Most patients requiring medical care are transported via motorcycle taxis or on foot. This project evaluates the feasibility and impact of a train-the-trainer program designed to improve capacity of community members to provide initial emergency care through contextually adapted first aid skills. Methods: This observational cohort study identified a geographically representative cohort of leaders to serve as trainers. These leaders were trained to teach a locally oriented first aid curriculum designed in concert with Haitian partners. This curriculum emphasized use of readily available materials in provision of care and was aimed at locally prevalent conditions. An accompanying Haitian Creole course manual with embedded teaching guides was developed. These trainers in turn trained local community members, with recruitment focused on local drivers who can ultimately act as de facto first responders in the region. Results: Thirty-five individuals were recruited, of which 51.4% achieved criteria to become independent trainers. Within 6 months of the initial training course, 44.8% of trainers reported using the skills they had been taught. The trainers taught 271 community members first aid skills within the study period. Of these, 33.1% of participants reached in follow-up surveys reported providing first aid in their communities and 19.8% had transported persons in need of emergency care to a healthcare facility since completion of the course. Conclusions: This train-the-trainer model is an effective method for strengthening the capacity of communities to care for medical emergencies in the Northeast region of Haiti. This program may be important to building a future formal EMS system in the region and may be applicable to similar resource-limited settings. The following core competencies are addressed in this article: Patient Care, Medical Knowledge, System-Based Practice.

Thoughts, Ethics and Actions in EMS photography

&lt;p&gt;“Photography can only represent the present. Once photographed, the subject becomes part of the past.” Berenice Abbott (July 17, 1898 – December 9, 1991). To me photography is about capturing a moment, a single moment in time, a single image. Most of us these days are amateur photographers with our camera phones. A picture tells a thousand words they say. A bride on her wedding day, a child killed by a bombing, a beautiful mountain range, a riot, boats , hurricanes...anything you take a photo of is a moment in time, a split second… then it is history.&lt;/p&gt;&lt;p&gt;So what role does photography have in Emergency Medical Services (EMS)? It's about education, history, promoting, documenting, recording. Looking back on old photographs we can see how far we have come in terms of equipment, personnel, and training. Without the photos we would have no reference point. It’s a sobering thought that the photos we take today in good faith may in fact be the warnings of tomorrow. &lt;/p&gt;&lt;p&gt;Who doesn’t love to look back at photographs when they first started in EMS? Looking to pick out who is still in the job, who has lost the most hair and maybe who has passed away. Sitting around a table, having a cup of coffee with your colleagues, talking about a call you just did, maybe a bad call, someone breaks the tension; “Time for a photo?” Most will smile and join in, some will refuse - each to their own, but a time will come when you look back on these photos remembering not only the bad call but also remembering who had your back that day.&lt;/p&gt;&lt;p&gt;Formal EMS events provide a means to mingle and connect and a chance for a photographer to capture a moment in time, the atmosphere, the faces, the colour, the pomp. But in fact, this is also recording history of the EMS staff at that moment in time.&lt;/p&gt;&lt;p&gt;Of course there is a graphic side to EMS photography. Photographers will be held to account to portray individuals and scenes with the utmost respect to the patient and their families.(1) Passers-by can be opportunistic and sometimes thoughtless at crisis scenes.(2) So we ask...is it okay to photograph a person in their last few minutes? Graphic photos taken by EMS personnel can be used as a training tool, a reference point and a visual aid when you get to the emergency department. Like a T- boned car, a bullseye impact in the windscreen… a picture tells a thousand words. But where is the line drawn…or is there a difference?&lt;/p&gt;&lt;p&gt;The National Press Photographers Association (NPPA) Code of Ethics Summary guide expresses this nicely as: “Photographic and video images can reveal great truths, expose wrongdoing and neglect, inspire hope and understanding and connect people around the globe through the language of visual understanding. Photographs can also cause great harm if they are callously intrusive or are manipulated”.(3)&lt;/p&gt;

Reducing road traffic deaths: where should we focus global health initiatives?

BackgroundCurrent global surgery initiatives focus on increasing surgical workforce; however, it is unclear whether this approach would be helpful globally, as patients in low-resource countries may not be able to reach hospitals in a timely fashion without formal Emergency Medical Services (EMS). We hypothesize that increased surgical workforce correlates with decreased road traffic deaths (RTDs) only in countries with EMS. MethodsEstimated RTDs were obtained from the Global Status Report on Road Safety 2013, which estimated the RTD rate in 2010 (RTD 2010). The classification of EMS was defined by the Global Status Report on Road Safety 2009. The density of surgeons, anesthesiologists, and obstetricians (SAO density) and 2010 income classification were accessed from the World Bank. Multivariable regression analysis was performed adjusting for different countries, income levels, and trauma system characteristics. Sensitivity analysis was performed. ResultsOne-fourth of the countries reported not having formal EMS (n = 41, 23.4%). On adjusted analysis, SAO density was not associated with changes in RTD 2010 in countries without EMS (n = 25, P = 0.50). However, in countries with EMS, each increase in SAO density per 100,000 population decreased RTDs by 0.079 per 100,000 population (n = 97, P <0.001). Income was the only other factor resulting in reduced mortality rates (P = 0.004). Sensitivity analysis confirmed these findings. ConclusionsIncreases in surgical workforce reduce RTDs only when EMS exist. Surgical workforce and EMS must be seen as part of the same system and developed together to maximize their effect in reducing RTDs. Global health initiatives should be tailored to individual country need. Level of EvidenceLevel II (Ecological study).

Variable Impact of State Legislative Advocacy on Registry Participation and Regional Systems of Care Implementation

Regionalization, systems of care design, and quality improvement (QI) registry participation all promote the widespread dissemination of guideline-based evidence into actual practice. As a result, policy statements from the American Heart Association/American Stroke Association (AHA/ASA) advocate for the creation of regional systems of care for various time-critical diagnoses, including ST-elevation myocardial infarction (STEMI), out-of-hospital cardiac arrest resuscitation, and acute stroke.1–3 Creation of these regional networks requires multidisciplinary collaboration to implement 5 mutually reinforcing core elements4 that build each system: (1) Designation of certain hospitals with special treatment capabilities as Receiving Centers for STEMI, resuscitation, or stroke; (2) emergency medical services (EMS) destination protocols that allow for direct transport of certain patients identified by explicit triage criteria to a designated Receiving Center, thus allowing for bypass of closer hospitals if they lack the needed specialty service; (3) organized interhospital transfer and transport protocols to a Receiving Center for appropriate patients who initially self-present or are mistriaged to a Referral Hospital; (4) communication or telemedicine options to provide real-time expert consultation as needed from a Receiving Center to its associated Referral Hospitals or EMS providers; and (5) participation in a regional and/or national QI registry to track relevant process-of-care metrics and meaningful risk-adjusted clinical outcomes. Within each of the 50 states, unique challenges exist for stakeholders attempting to implement the 5 aforementioned core elements of regional or statewide systems of care. In particular, substantial variation exists with regard to the starting point for these initiatives. For example, some states already have sufficient regulatory authority within their EMS agency or state department of health (DOH) to regionalize care of time-critical diagnoses, whereas other states require new legislation to create coordinated systems. In October 2011, the Advocacy Coordinating Committee of the AHA convened a multispecialty task force to assess the …

Assessment of the Status of Prehospital Care in 13 Low- and Middle-Income Countries

Background. Injury and other medical emergencies are becoming increasingly common in low- and middle-income countries (LMICs). Many to most of the deaths from these conditions occur outside of hospitals, necessitating the development of prehospital care. Prehospital capabilities are inadequately developed to meet the growing needs for emergency care in most LMICs. Objective. In order to better plan for development of prehospital care globally, this study sought to better understand the current status of prehospital care in a wide range of LMICs. Methods. A survey was conducted of emergency medical services (EMS) leaders and other key informants in 13 LMICs in Africa, Asia, and Latin America. Questions addressed methods of transport to hospital, training and certification of EMS providers, organization and funding of EMS systems, public access to prehospital care, and barriers to EMS development. Results. Prehospital care capabilities varied significantly, but in general were less developed in low-income countries and in rural areas, where utilization of formal EMS was often very low. Commercial drivers, volunteers, and other bystanders provided a large proportion of prehospital transport and occasionally also provided first aid in many locations. Although taxes and mandatory motor vehicle insurance provided supplemental funds to EMS in 85% of the countries, the most frequently cited barriers to further development of prehospital care was inadequate funding (36% of barriers cited). The next most commonly cited barriers were lack of leadership within the system (18%) and lack of legislation setting standards (18%). Conclusions. Expansion of prehospital care to currently underserved or unserved areas, especially in low-income countries and in rural areas, could make use of the already-existing networks of first responders, such as commercial drivers and laypersons. Efforts to increase their effectiveness, such as more widespread first-aid training, and better encompassing their efforts within formal EMS, are warranted. In terms of existing formal EMS, there is a need for increased and more regular funding, integration and coordination among existing services, and improved organization and leadership, as could be accomplished by making EMS administration and leadership a more desirable career path.

Prehospital Trauma System Reduces Mortality in Severe Trauma: A Controlled Study of Road Traffic Casualties in Iraq

In low-resource communities with long prehospital transport times, most trauma deaths occur outside the hospital. Previous studies from Iraq demonstrate that a two-tier network of rural paramedics with village-based first helpers reduces mortality in land mine and war-injured from 40% to 10%. However, these studies of prehospital trauma care in low-income countries have been conducted with historical controls, thus the results may be unreliable due to differences in study contexts. The aim of this study was to use a controlled study design to examine the effect of a two-tier prehospital rural trauma system on road traffic accident trauma mortality. A single referral surgical hospital was the endpoint in a single-blinded, non-randomized cohort study. The catchment areas consisted of some districts with no formal Emergency Medical Services (EMS) system, and other districts where 95 health center paramedics had been trained and equipped to provide advanced life support, and 5,000 laypersons had been trained to give on-site first aid. The hospital staff registered trauma mortality and on-admission physiological severity blindly. Assuming that prehospital care would have no significant impact on mortality in moderate injuries, only road traffic accident (RTA) casualties with an Injury Severity Score (ISS)≥9 were selected for study. During a three-month study period, 205 patients were selected for study (128 in the treatment group and 77 in the control group). The mean prehospital transit time was approximately two hours. The two groups were comparable with regards to demographic characteristics, distribution of wounds and injuries, and mean anatomical severity. The mortality rate was eight percent in the treatment group, compared to 44% in the control group (95% CI, 25%-48%). Adjusted for severity differences between the treatment and control groups, prehospital care was a significant contributor to survival. Where prehospital transport time is long, a two-tier prehospital system of trained paramedics and layperson first responders reduces trauma mortality in severe RTA injuries. The findings may be valid for civilian Emergency Medical Services interventions in other low-resource countries.