Village university - delegating lifesaving skills to non-doctors
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The Village University- save lives, save limbs
Ole-Kristian Losvik – [email protected]
Tromsoe Mine Victim Resource Center
Soria Moria 13.Sept 2011
Kongsberg model. Photo: US NavyTromsø model. Photo: TMC.
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umacare
.no
Epidemic of Trauma
• Every year 120 million persons are injured in low- and middle-income countries as compared to 11 million casualties in the high-income countries
• A worldwide epidemic of trauma is on. Injury is now the 4th leading cause of global deaths.
• WHO estimates a further 40% increase in global deaths from injury up to year 2030
• Tromsø Mine Victim ResourceCenter works mainly with supportfor war victims
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Village first helpers (Thousands)
Paramedics (hundreds)
Local doctors (a few)
Save lives, save limbs
• 40% of land mine victims will die before reaching a hospital unless somebody is there to provide life support on the way (pre-intervention survey)
• In cooperation with local health authorities we trained paramedics in Iraq and Cambodia to take care of land mine victims. Part of the paramedic training was teaching village first helpers.
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The training
• Understand ‘oxygen starvation’• Clinical examination, BLS and CPR• Focus on trauma victims with injured limbs
1st training course, Basic Life Support,
150 hours
• Stabilize and evacuate trauma victims• Teach Village First Responders
Working period, 4–6 months
• Rehearsal of BLS/CPR skills• Focus on ‘the difficult airway’• Advanced CPR
2nd training course, Advanced Trauma Life
Support, 150 hours
• Stabilize and evacuate trauma victims• Teach Village First Responders
Working period, 4–6 months
• Rehearsal of course 1 and 2• Focus on chest injured• Nutrition for trauma victims
3rd training course, Advanced Trauma Life
Support, 150 hours
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Interventions
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Can simple measures save their lives?
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The village university• Delegating life saving skills to non-doctors• Temporary university campus• Students are seleceted locally and should be trusted and wellknown
in their community• Practical and some theory, but no academic acrobatics• Research (to be continued…)
Ref: Husum H, Gilbert M, Wisborg T. Training pre-hospital trauma care in low-income countries: the 'Village University' experience. Med Teach 2003;25(2):142-148.
Village First Helper training Vietnam (2007)
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Teaching Manual
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Injury Charts
• The learning and training are also supported by the injury chart.
• Injury charts serves as a checklist for examination and also for treatment.
• The paramedics report that injury chart is useful for evaluating their own job.
• It is also used by local supervisors to ensure high quality of care.
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Time to first medical help
Mean time to first medical help by year
Year
1997 1998 1999 2000 2001 2002 2003 2004
Me
an
tim
e t
o f
irst
me
dic
al h
elp
(h
ou
rs)
0,0
0,5
1,0
1,5
2,0
2,5
3,0
3,5
(data from North Iraq 1997-2004)
Mortality by year
Year
1997 1998 1999 2000 2001 2002 2003 2004
Pro
bab
ility
of
De
ath
0,00
0,05
0,10
0,15
0,20
0,25
0,30
0,35
Mo
rtal
ity
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Paramedic retention• In North Iraq:
Out of 88 paramedics certified in the years 1996-2004, 63 of them was still present in program in November 2005.
Osman Hama Salah has trained several hundred first helpers during years as a paramedic
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Take home message
• After implementation of a low cost rural rescue system, there was a significant reduction in trauma mortality from 26.2% in 1997 to 11.8% in 2001. The mortality was stable after that.
• This shows that low-cost prehospital trauma systems improve survival in land mine victims where prehospital transit times are high.
• After trauma care training at rural makeshift training centers, non-graduate health workers can build efficient and sustainable rural rescue system
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Ketamine pain relief
• Opioid analgesics is the “standard” for prehospital pain relief, however with some potential fatal side effects like respiratory depression, hypotension and loss of protective airway reflexes.
• In North Iraq paramedics have been using ketamine analgesia for 10 years.
• Aim: compare the effect of ketamine and opioids on physiologic severity indicators through retrospective study in Iraq, and prospective study in Vietnam.
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Method (Iraq study)
• Retrospective interventional study in a trauma registry with parallel group design: no analgesia (n=275), opioid analgesia (n= 888), and ketamine analgesia (n=713).
• Physiologic severity score was calculated based on rated values for respiratory rate, blood pressure, and consciousness.
• Explanatory variable were analyzed in generalized linear model.
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Preliminary analysis (Iraq study)
• Paramedic administration of analgesia is associated with positive change in physiologic severity score outcome (p=0.01) in a low-resource prehospital trauma system.
• The two groups receiving analgesia has a significant better positive change for respiration (p=0.0001) and blood pressure (p<0.0001).
• Ketamine analgesia is significantly better than opioid analgesia (p=0.0002) for blood pressure in patients with Injury Severity Score more than 8.
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Upcoming study…• In the jungle of Cambodia some farmers have made a prosthesis
workshop, with support from TMC and donors. • Most disabled survivors in the South suffer from incapacitating pain
syndromes. Can Early Temporary Walking Aid made of local materials by local technicians prevent chronic pain and promote function?
$6000
$600
Photo: Ben Robinson
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Further reading…
• Fosse E, Husum H: Surgery in Afghanistan: a light model for field surgery during war. Injury 1992; 23: 401 – 404.
• Husum H. Effects of early prehospital life support to war injured: the battle of Jalalabad, Afghanistan. Prehosp Disast Med 1999; 14: 75 – 80.
• Husum H, Gilbert M, Wisborg T. Training prehospital trauma care in low-income countries: the “Village University” experience. Med Teach 2003; 25: 142 – 48.
• Husum H, Strada G. Measuring injury severity. The ISS as good as the NISS for penetrating injuries. Prehosp Disast Med 2002; 17: 27 – 32.
• Husum H, Gilbert M, Wisborg T, Heng YV, Murad M. Rural prehospital trauma systems improve trauma outcome in low-income countries: a prospective study from North Iraq and Cambodia. J Trauma 2003; 55: 466 – 70.
• Husum H, Gilbert M, Wisborg T, Heng YV, Murad M. Landmine injuries: a study of 708 victims in North Iraq and Cambodia. Mil Med 2003; 168: 934 – 39.
• Husum H, Olsen T, Murad M, Heng YV, Wisborg T, Gilbert M. Preventing postinjury hypothermia during long prehospital evacuation. Prehosp Disast Med 2002; 17: 23 – 26.
• Husum H, Gilbert Mlocal know-how”. The Cartagena Summit on a Mine-free world, Colombia, December 2009.
• Murad MK, Larsen S, Husum H. What makes a survivor? Ten year Rs of experience with a trauma system in Iraq. WHO Bulletin 2011 (submitted).
• , Wisborg T, Heng YV, Murad M. Respiratory rate as prehospital triage tool in rural trauma. J Trauma 2003; 55: 466 – 70.
• Husum H, Resell K, Vorren G, Heng YV, Murad M, Gilbert M, Wisborg T. Chronic pain in landmine accident survivors in Cambodia and Kurdistan. Soc Sci Med 2002; 55:1813 – 16.
• Husum H, Heger T, Sundet M. Postinjury malaria: a study of trauma victims in Cambodia. J Trauma 2002; 52: 259 – 66.
• Sundet M, Heger T, Husum H. Postinjury malaria: a risk factor for wound infection and protracted recovery. Trop Med Int Health 2003; 9: 238 – 42.
• Heger T, Sundet M, Heng YV, Rattana Y, Husum H. Postinjury malaria: experiences of doctors in Battambang Province, Cambodia. SEAsian J Trop Med 2005; 36: 811 – 15.
• Hedelin H, Husum H, Mudhafar M, Edvardsen O. Traumavard i fattiga lander - en bys kollektiva angelagenhet. Omhandertagandet av minskadade pa landsbygden i norra Irak [summary] . Sv Laktid 2006; 7: 460 – 63.
• Edvardsen, O. Et nettverk av førstehjelpere i det minelagte Nord-Irak: et spørsmal om liv eller død. Thesis, Master Health Science. Tromso University, 2006.
• Chandy H, Steinholt M, Husum H. Delivery Life Support: chain-of-survival for complicated deliveries in rural Cambodia, a preliminary report. Nurs Hlth Sci 2007; 9; 263 – 269.
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• Chandy H, Ol HS, Heng YV, Husum H. Comparing two survey methods for maternal and neonatal mortality in rural Cambodia. Women Birth 2008; 21: 9-12
• Tajsic N, Husum H. Reconstructive microsurgery can be done in low-resource settings: experiences from a wartime scenario. J Trauma. 2008; 65:1463-7.
• Heng YV, Davoung C, Husum H. Trauma surgery at the District Hospital: a controlled study of trauma training for rural non-graduate surgeons in Cambodia. Prehosp Disast Med 2008; 23: 483 – 90
• Wisborg T, Murad M, Edvardsen O, Husum H. Trauma systems in Iraq 1997-2004: adaptation and maturation. J Trauma 2008; 64: 1342 – 48
• Tajsic N, Winkel R, Hoffmann R, Husum H. Sural perforator flap for reconstructive surgery in the lower leg and the foot: a clinical study of 86 patients with post-traumatic osteomyelitis. J Plast Reconstr Aesthet Surg 2009: 62: 1701 – 8
• Husum H, Edvardsen. Trauma as Poverty. Methodological problems when reality gets nasty. In: Ingstad B, Eide H. Disability and Poverty (London 2009, in press).
• Ol HS, Bjoerkvoll B, Sothy S, Heng YV, Hoel H, Husebekk A, Gutteberg T, Larsen S, Husum H. Prevalence of Hepatitis B and Hepatitis C virus infection in potential blood donors in rural Cambodia. Se Asian J Trop Med 2009; 40: 963 – 71
• Heger T, Han SC, Sundet M, Larsen S, Husum H. Early diagnosis and treatment of malaria Falciparum in Cambodian trauma patients. SE Asian J Trop Med 2009; 40: 1135 – 47
• Husum H. Severity scoring in rural trauma. Rural Remote Hlth 9 (online) 2009: 1226
• Tajsi! N, Winkel R, Schlageter M, Hoffmann R, Husum H. Saphenous perforator flap for
reconstructive surgery in the lower leg and the foot; a clinical study of 50 patients with post- traumatic osteomyelitis. J Trauma 2010; 68: 1200 – 7
• Husum H. Rural trauma in Iran: are the data reliable? Rural Remote Hlth 10 (online) 2010: 1387
• Heng YV, Husum H, Murad MK, Wisborg T. Improving rural prehospital care in the absence of formal emergency medical services. In: Mock C, Julliard C, Joshipura M, Goosen J (Eds). Strengthening care for the injured: Success stories and lessons learned from around the world. World Health Organization, Geneva 2010: 3 – 7
• Murad M, Husum H. Trained lay first-helpers reduce trauma mortality: a controlled study of rural trauma in Iraq. J Prehosp Disast Med 2010; 25:533 – 39
• Bjoerkvoll B, Viet L, Ol S, Lan TN, Sothy S, Hoel H, Husebekk A, Gutteberg T, Larsen S, Husum H.: Screening test accuracy among potential blood donors. Poor rapid test result accuracy in screening of potential blood donors of HbsAg, anti-HBc and anti-HCV to detect hepatitis B and c virus infection in rural Cambodia and Vietnam: Southeast Asian Journal of Trop Med Public Health, volume 41, September 2010.
• Viet L, Lan TN, Ty PX, Hoel H, Husebekk A, Gutteberg T, Larsen S, Husum H. Prevalence of hepatitis B and hepatitis C virus infections in potential blood donors in rural Vietnam. Ind J Med Res 2010 (submitted)
• Lejon, H, Edvardsen, O, Husum, H: A qualitative study of first level care providers in rural Cambodia: Are Traditional Birth Attendants skilled or non-skilled care providers? University of North Norway, Tromsoe
• Husum, Hans: “Immediate temporary prosthesis, local material and
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Thanks…
• Thanks to NorwegianMinistry of Foreign Affairs for supportthrough 15 years!
MFA
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