Search

To evaluate the teaching effect of a trauma training program in emergency cranial neurosurgery in Cambodia on surgical outcomes for patients with traumatic brain injury (TBI). We analyzed the data of TBI patients who received emergency burr-hole trephination or craniotomy from a prospective, descriptive cohort study at the Military Region 5 Hospital between January 2015 and December 2016. TBI patients who underwent emergency cranial neurosurgery were primarily young men, with acute epidural hematoma (EDH) and acute subdural hematoma (SDH) as the most common diagnoses and with long transfer delay. The incidence of favorable outcomes three months after chronic intracranial hematoma, acute SDH, acute EDH, and acute intracerebral hematoma were 96.28%, 89.2%, 93%, and 97.1%, respectively. Severe traumatic brain injury was associated with long-term unfavorable outcomes (Glasgow Outcome Scale of 1–3) (OR = 23.9, 95% CI: 3.1–184.4). Surgical outcomes at 3 months appeared acceptable. This program in emergency cranial neurosurgery was successful in the study hospital, as evidenced by the fact that the relevant surgical capacity of the regional hospital increased from zero to an acceptable level. publishedVersion

ObjectiveThe majority of maternal and perinatal deaths are preventable, but still women and newborns die due to insufficient Basic Life Support in low-resource communities. Drawing on experiences from successful wartime trauma systems, a three-tier chain-of-survival model was introduced as a means to reduce rural maternal and perinatal mortality.MethodsA study area of 266 villages in landmine-infested Northwestern Cambodia were selected based on remoteness and poverty. The five-year intervention from 2005 through 2009 was carried out as a prospective study. The years of formation in 2005 and 2006 were used as a baseline cohort for comparisons with later annual cohorts. Non-professional and professional birth attendants at village level, rural health centers (HCs), and three hospitals were merged with an operational prehospital trauma system. Staff at all levels were trained in life support and emergency obstetrics.FindingsThe maternal mortality rate was reduced from a baseline level of 0.73% to 0.12% in the year 2009 (95% CI Diff, 0.27-0.98; PConclusionThe results correspond to experiences from modern prehospital trauma systems: Basic Life Support reduces maternal and perinatal death if provided early. Trained TBAs are effective if well-integrated in maternal health programs.HouyC,HaSO,SteinholtM,SkjerveE,HusumH.Delivery as trauma: a prospective time-cohort study of maternal and perinatal mortality in rural Cambodia.Prehosp Disaster Med.2017;32(2):180–186.

A prospective interventional study has been carried out on the teaching effect and sustainability of low-cost trauma training program in open tibia fracture management for health workers. In 2007, an external fixator and a patella-bearing orthosis were developed at a rural workshop in Cambodia. From 2010 to 2016, a core group of nine Cambodian health workers was trained in open fracture management by Norwegian senior surgeons, using the locally made fixator and brace. The training outcome was also assessed by a questionnaire comprising of assertions regarding theoretical understanding, technical skills and self-confidence in understanding the biomechanical properties of locally made external fixator and its application; the use of handmade orthosis and principle in covering of soft-tissue defects. The students managed 23 cases with the new technique with a primary healing rate of 70% (95% CI 48.1–85.5). A significant increase in self-reported technical skills, understanding, and self-confidence was reported. This study demonstrates that the capacity building of reconstructive surgery in low-resource settings by local doctors and paramedics is clearly a reasonable option that may substantially reduce amputation of the limbs.

The use of opioid analgesics in prehospital trauma care has been reported to have negative side effects on the airway and circulation. Several studies of urban trauma management have recommend ketamine as a safe and efficient analgesic. To date, however, no controlled trials of prehospital opioid analgesics versus ketamine in rural trauma management have been published.This study aimed to compare the analgesic effects and side effects of ketamine and morphine in a prehospital, low-resource setting.The study was conducted with a prospective, cluster-randomized design. The Quang Tri province of Vietnam was divided into two sectors that alternated monthly between ketamine and morphine treatments. A total of 169 trauma patients were treated outside hospital settings with ketamine, while 139 patients were treated with morphine.The treatment effects were measured by comparing the Visual Analogue Scale (VAS) ratings in the field to those upon on admission. The analgesic effects were positive and similar for the two drugs. The rate of vomiting was significantly lower in the ketamine group (5%) than in the morphine group (19%, 95% CI for difference 8-22%). The rate of hallucinations and agitation was higher in ketamine-treated patients (11%) than in the morphine-treated patients (1.5%, 95% CI for difference 4-16%). In this study, patients with head trauma (n = 57) showed no adverse effects on consciousness level after being treated with ketamine.Ketamine had an analgesic effect similar to morphine and carried a lower risk of airway problems. The risk of hallucinations and agitation was increased in the ketamine group. These findings are of medical significance, particularly in rough and low-resource scenarios.

SUMMARY Background and objective: Transfusion-transmitted hepatitis B virus (HBV) infection may originate from hepatitis B surface antigen (HBsAg) false-negative blood donors, HBsAg negative and anti-HBc positive blood donors and blood donors with both tests negative. HBV DNA may be present in all these cases and blood may be infectious. The aim of the study was to estimate the risk of transfusion-transmitted HBV in Vietnam using a stochastic Monte Carlo model. Methods: A cross-sectional study of HBV prevalence in 1200 potential blood donors in rural Vietnam is used as basis for the Monte Carlo model together with expert panel estimates of occult hepatitis B infection (OBI) prevalence in blood donors. Results: With 1 000 000 blood donors running in the model, the potential OBI ranged from 658 to 747 blood units per million at 5 percentile and from 1342 to 2507 blood units per million at 95 percentile resulting in the risk of post-transfusion hepatitis ranging from 66 to 250 blood units per million assuming that risk of post-transfusion from potential OBI is 10%. Using the manufacturer’s HBsAg sensitivity, the mean rate of blood units per million donations having false-negative HBsAg results was 298 (5–95 percentile: 14–893). When the test sensitivity was set lower, false-negative tests was observed at a mean of 1087 per million (5–95 percentile: 762–3220). The fraction of potential OBI donors increased with the increasing age in both genders. Conclusion Current HBsAg screening in Vietnam is insufficient in eliminating the risk of transfusion-transmitted HBV infection. The major risk factors are HBsAg false-negative results and OBI. Increased test sensitivity and locally validated HBsAg assays are recommended.

Objective Replacement of full thickness soft tissue defects in the lower leg and ankle, appropriate to the defect and following the course of blood vessels feeding the skin of a distally hinged fasciocutaneous flap most reliably based on the individual anatomy of distal perforators of the posterior tibial artery. Indications Full thickness soft tissue defects, up to 12 cm in length and up to 8 cm in width. Sufficient vascularization of the foot required, in osteomyelitis, and when joints, fractures, implants and tendons are exposed and when a split skin graft, a local flap, a suralis perforator flap or a free flap is not indicated. Contraindications For patients, in whom a 1-2 h operation is not possible; necessity of angioplasty; decollement or scars around the distal perforators of the posterior tibial artery; local infection or necrosis of soft tissues and/or bone, which cannot be totally excised. Surgical technique Radical debridement; flap dissection without tourniquet; microdissection; design of the flap on the skin: pivot point ~ 10 cm (6-14 cm) proximal of the tip of the medial malleolus; base ~ 5 cm in width, between the course of the saphenous nerve and of the great saphenous vein and the Achilles tendon; adipofascial pedicle up to 15 cm in length sited over the septum between soleus and flexor digitorum muscles, following the course of the saphenous nerve, with a central skin stripe, which expands into a proximal skin island; skin island is outlined similar to the defect, but larger by 1 to 2 cm, surrounded by an adipofascial border: adjustment of the planning as well as of the elevation of these flaps according to the individual position and the caliber of perforators requires in each case the search for a perforator at the estimated pivot point. Delay of transposition, if the division of more than one perforator proximal to the pivot point obviously diminishes circulation. No "tunnelling "of the pedicle; defects of skin due to the elevation of the flap are replaced by split and meshed skin grafts or temporary by "artificial skin". A gap in the bandage over the skin island allows for observation. Postoperative management Protocol of controls of vascularization: color and time for revascularization; antibiotic treatment according to bacteriological testing. In case of edema or discoloration of the flap: immediate removal of sutures, administration of leeches, operative revision. Split skin graft 1 week after flap transposition, if the skin had been temporary substituted. Results Retrospective uncontrolled study with over 70 saphenous perforator flaps from 1995-2011. Full soft tissue defects 62 times with osteomyelitis, 3 times with endoprothesis, 3 times with fractures, 2 times with exposed tendons. From 1995-2006, 44/50 (88 %) flaps healed completely or at least to 3/4 without the necessity of further flaps; from 2007-2011, 13/20 (65 %) flaps healed completely and 6/20 (30 %) flaps healed at least to 3/4 without the necessity of further flaps, loss of one flap (5 %).

Introduction:Recent studies demonstrate that early, in-field, basic life support by paramedics improves trauma survival where prehospital transport times are long. So far, no case-control studies of the effect of layperson trauma first responders have been reported. It was hypothesized that trained layperson first responders improve trauma outcomes where prehospital transit times are long.Methods:A rural prehospital trauma system was established in the mine and war zones in Iraq, consisting of 135 paramedics and 7,000 layperson trauma first responders in the villages. In a non-randomized clinical study, the outcomes of patients initially managed in-field by first-responders were compared to patients not receiving first-responder support.Results:The mortality rate was significantly lower among patients initially managed in-field by first responders (n = 325) compared to patients without first-responder support (n = 1,016), 9.8% versus 15.6%, 95% CI = 1.3−10.0%.Conclusions:Trained layperson first responders improve trauma outcomes where prehospital evacuation times are long. This finding demonstrates that simple interventions done early—by any type of trained care provider—are crucial for trauma survival. Where the prevalence of severe trauma is high, trauma first-responders should be an integral element of the trauma system.

Summary Background The treatment of post-traumatic osteomyelitis of the lower leg and the foot remains a challenge in reconstructive surgery. Material and methods Eighty-six patients with lower leg post-injury chronic osteomyelitis were included in a retrospective, non-controlled clinical study conducted from 1995 to 2006. All study patients were managed by distally based sural neuro-fascio-cutaneous perforator flap. An endpoint survey was conducted after flap surgery and had a mean follow-up period of 5.5 years, wherein the response rate was 48%. Results Seven patients had a short-term flap failure (8%; 95% CI 3−16%). An additional eight patients (7%) had flap necrosis of less than one-fourth of the flap that healed without surgical revision. Based on the endpoint data, the long-term success rate was 87% (95%, CI 72–96%). Local and/or systemic physiological compromise was a risk factor for flap failure. Other assumed risk factors had no statistically significant impact on short- or long-term results. Conclusion Sural perforator flap is a robust flap with low failure rate, even in high-risk patients. The success rate compares favourably with results of free flap transfers in the management of post-traumatic osteomyelitis. The flap has a wide range, and the surgical technique is rather simple. The sural flap is a feasible option for post-traumatic reconstructions of osteomyelitis, especially in low-resource settings.

Summary Purpose We need solid estimates of maternal mortality rates (MMR) to monitor the impact of maternal care programs. Cambodian health authorities and WHO report the MMR in Cambodia at 450 per 100,000 live births. The figure is drawn from surveys where information is obtained by interviewing respondents about the survival of all their adult sisters (sisterhood method). The estimate is statistically imprecise, 95% confidence intervals ranging from 260 to 620/100,000. The MMR estimate is also uncertain due to under-reporting; where 80–90% of women deliver at home maternal fatalities may go undetected especially where mortality is highest, in remote rural areas. The aim of this study was to attain more reliable MMR estimates by using survey methods other than the sisterhood method prior to an intervention targeting obstetric rural emergencies. Procedures The study was carried out in rural Northwestern Cambodia where access to health services is poor and poverty, endemic diseases, and land mines are endemic. Two survey methods were applied in two separate sectors: a community-based survey gathering data from public sources and a household survey gathering data direct from primary sources. Findings There was no statistically significant difference between the two survey results for maternal deaths, both types of survey reported mortality rates around the public figure. The household survey reported a significantly higher perinatal mortality rate as compared to the community-based survey, 8.6% versus 5.0%. Also the household survey gave qualitative data important for a better understanding of the many problems faced by mothers giving birth in the remote villages. There are detection failures in both surveys; the failure rate may be as high as 30–40%. Principle conclusion Both survey methods are inaccurate, therefore inappropriate for evaluation of short-term changes of mortality rates. Surveys based on primary informants yield qualitative information about mothers’ hardships important for the design of future maternal care interventions.

OBJECTIVE To assess the impact of post-injury falciparum malaria on morbidity parameters in Cambodia. METHOD Retrospective study of 227 trauma patients managed at a surgical centre in Battambang, Cambodia. RESULTS Within 10 days of the injury, 42.7% of the study population developed symptomatic malaria. In patients with post-injury malaria, the rate of wound infection was 36.1% compared with 10.0% in patients without symptomatic malaria (95% confidence interval for difference 15.2-36.9%). The average hospital stay in the post-injury malaria group was 31.2 days compared with 19.4 days in the patients without the complication (95% confidence interval for difference 7.2-16.4 days). CONCLUSION Symptomatic malaria after trauma is common in Cambodia. Post-injury malaria seems to increase the risk of wound infection, delays postoperative recovery, and thus adds to the burden of trauma.

Introduction:Post-injury hypothermia is a risk predictor in trauma patients whose physiology is deranged. The aim of the present study was to examine the effect of simple, in-field, hypothermia prevention to victims of penetrating trauma during long prehospital evacuations.Methods:A total of 170 consecutively injured landmine victims were included in a prospective, clinical study in Northern Iraq and Cambodia. Thirty patients were provided with systematic prehospital hypothermia prevention, and for 140 patients, no preventive measures were provided.Results:The mean value for the time from injury to hospital admission was 6.6 hours (range: 0.2–72). The incidence of hypothermia (oral temperature Conclusion:Simple, preventive, in-field measures help to prevent hypothermia during protracted evacuation, and should be part of the trauma care protocol in rural rescue systems.

Background: The pattern of host defense against plasmodium is comparable to the immune response to bacterial infection. Posttraumatic immunosuppression may therefore cause relapses of malaria secondary to trauma and trauma surgery in asymptomatic carriers of the parasites in endemic areas. To our knowledge this has not been validated in epidemiologic studies. Methods: Postinjury malaria was registered retrospectively in 342 land mine and war victims from malaria-endemic areas in Cambodia. The incidence rate was analyzed in terms of age, gender, preinjury endemicity, evacuation times, anatomic injury severity, systolic blood pressure at admission, blood transfusion, and duration of the first surgical intervention as independent variables. Results: The rate of postinjury malaria in the study patients was 33.3% (95% CI, 28.3-38.3%). Injury Severity Score (ISS) and surgical operation time were risk factors (area under the curve in receiver operating characteristic plots were 0.73 and 0.79, respectively). The impact of the other risk factors was nonsignificant. Conclusion: Despite difficulties in diagnosing postoperative malaria in endemic areas, the study demonstrates that the rate of postinjury malaria is high. The results legitimate controlled trials of immediate postinjury chemoprophylaxis to severely injured in endemic areas. The authors recommend staged surgical operations with brief primary interventions in victims with severe injuries.

Study aims To report the surgical anatomy of the perforator arteries at the lower leg, analyse clinical outcomes in previous studies, and forward methodological recommendations for future studies of post-traumatic perforator flap reconstructions. Methods A study sample of 640 human patients drawn from 24 clinical reports was included for review. The sample comprised of four subsets: sural flap reconstructions ( n = 257), saphenous flaps ( n = 122), supramalleolar flaps ( n = 92), and propeller flaps ( n = 169). Results Statistical analysis of samples from anatomical studies documents significant differences in the perforator distribution from the tibial and peroneal artery; peroneal perforator arteries are randomly organised whereas tibial artery perforators are clustered at three definite levels. The failure rates in clinical studies ranged from 0% to 6%, being lowest for supramalleolar flap reconstructions and highest for saphenous flaps; however, differences between the four subsets were not statistically significant at the 95% confidence level. Due to methodological flaws, outcome comparisons in the actual study sample should be interpreted cautiously; in most clinical studies both risk variables and outcome indicators are poorly defined. The outcome of Dynamic Infrared Thermography imaging of post-transposition changes of flap perfusion is reported. Summary Fasciocutaneous perforator flaps seem to have high survival rates and represent a feasible approach to post-traumatic reconstructions, especially in low-resource settings. A template for data gathering is recommended for higher accuracy in future comparative studies, and for scientific analysis of success and risk factors. New imaging techniques indicate a promising potential of micro-circular angiogenesis during the first two weeks after flap transpose.

The study examines the epidemiology of cluster weapon and land mine accidents in Quang Tri Province since the end of the Vietnam War. The province is located just south of the demarcation line and was the province most affected during the war. In 2009, a cross sectional household study was conducted in all nine districts of the province. During the study period of 1975-2009, 7,030 persons in the study area were exposed to unexploded ordnances (UXO) or land mine accidents, or 1.1% of the provincial population. There were 2,620 fatalities and 4,410 accident survivors. The study documents that the main problem is cluster weapons and other unexploded ordnances; only 4.3% of casualties were caused by land mines. The legacy of the war affects poor people the most; the accident rate was highest among villagers living in mountainous areas, ethnic minorities, and low-income families. The most common activities leading to the accidents were farming (38.6%), collecting scrap metal (11.2%), and herding of cattle (8.3%). The study documents that the people of the Quang Tri Province until this day have suffered heavily due to the legacy of war. Mine risk education programs should account for the epidemiological findings when future accident prevention programs are designed to target high-risk areas and activities.

Introduction: 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.Methods: 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.Results: 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.Conclusion: 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.

Background Blunt implementation of Western trauma system models is not feasible in low-resource communities with long prehospital transit times. The aims of the study were to evaluate to which extent a low-cost prehospital trauma system reduces trauma deaths where prehospital transit times are long, and to identify specific life support interventions that contributed to survival. Methods In the study period from 1997 to 2006, 2,788 patients injured by land mines, war, and traffic accidents were managed by a chain-of-survival trauma system where non-graduate paramedics were the key care providers. The study was conducted with a time-period cohort design. Results 37% of the study patients had serious injuries with Injury Severity Score ≥ 9. The mean prehospital transport time was 2.5 hours (95% CI 1.9 - 3.2). During the ten-year study period trauma mortality was reduced from 17% (95% CI 15 -19) to 4% (95% CI 3.5 - 5), survival especially improving in major trauma victims. In most patients with airway problems, in chest injured, and in patients with external hemorrhage, simple life support measures were sufficient to improve physiological severity indicators. Conclusion In case of long prehospital transit times simple life support measures by paramedics and lay first responders reduce trauma mortality in major injuries. Delegating life-saving skills to paramedics and lay people is a key factor for efficient prehospital trauma systems in low-resource communities.

The aim of this study was to determine the accuracy of rapid tests for HBsAg, anti-HBc and anti-HCV in rural Cambodia and Vietnam to detect hepatitis B and C. In a cross-sectional epidemiological study of two populations of 1,200 potential blood donors in rural Cambodia and Vietnam the prevalence rates of HBsAg, anti-HBc and anti-HCV as established by enzyme immunoassay (EIA) tests were compared to rapid test outcomes. The EIA reference test results were validated by Architect Chemiluminescent Microparticle Immunoassay (CMIA) technique. The actual rapid test demonstrated high specificity for all three test categories as claimed by the manufacturer. The test sensitivity observed was significantly lower than that claimed by the manufacturer: 86.5% for HBsAg, 86.6% for anti-HBc, and 76.4% for anti-HCV. There were large and significant variations in test performance between the two countries, especially for HBsAg detection. The low sensitivity of the actual rapid tests for HBsAg, anti-HBc and anti-HCV make them useless for blood donor screening in rural Southeast Asia. Rapid tests may be useful screening tools in blood transfusion services in low-resource settings, but tests should be carefully validated locally before being used for screening purposes since test performance varies by location.

An Iranian team has reported the results of a rural prehospital trauma system. In a previous comment to their article I asked the team to come forward with additional information in order to validate the accuracy of the main variable in their study, the physiological severity score (PSS) 2 . The Iranian colleagues responded promptly 3 and thus opened an important discussion on quality standards for trauma registry analysis.

The aims of the present study were to provide accurate prevalence of acute and occult hepatis B infection and hepatis C infection among potential blood donors in Cambodia and to study the accuracy of ELISA tests used for blood donor screening. A cross-sectional study was performed on samples collected from potential volunteer blood donors (n = 1,200) in two districts in rural Cambodia. The samples were tested using the ELISA technique for HBsAg, anti-HBc, and anti-HCV at a local blood bank. To validate the ELISA outcomes, a subset (n = 319) was analyzed by Automated Chemiluminescent Microparticle Immunoassay Technique (CMIA) at the University Hospital North Norway. The overall prevalence of the HBsAg positives was 7.7% (95% CI 6.2-9.3); the prevalence of anti-HBc positive samples was 58.6% (95% CI 55.8-61.4), and the prevalence of anti-HCV positive samples was 14.7% (95% CI 12.7-16.7). The prevalence rate of samples being both HBsAg positive and anti-HBc positive was 7.3% (95% CI 5.9 - 9.0), and the prevalence rate of HBsAg negative and anti-HBc positive samples was 51.2% (95% CI 48.4 - 54.1). The overall agreement between the ELISA and the CMIA test results was very high both for HBsAg and anti-HBc (kappa 0.93), and high for anti-HCV measurements (kappa 0.83). However, the false-negative rate for the ELISA anti-HCV test was as high as 15% (95% CI 6 - 30).

Introduction:Due to the accelerating global epidemic of trauma, efficient and sustainable models of trauma care that fit low-resource settings must be developed. In most low-income countries, the burden of surgical trauma is managed by non-doctors at local district hospitals.Objective:This study examined whether it is possible to establish primary trauma surgical services of acceptable quality at rural district hospitals by systematically training local, non-graduate, care providers.Methods:Seven district hospitals in the most landmine-infested provinces of Northwestern Cambodia were selected for the study. The hospitals were referral points in an established prehospital trauma system. During a four-year training period, 21 surgical care providers underwent five courses (150 hours total) focusing on surgical skills training. In-hospital trauma deaths and postoperative infections were used as quality-of care indicators. Outcome indicators during the training period were compared against pre-intervention data.Results:Both the control and treatment populations had long prehospital transport times (three hours) and were severely injured (median Injury Severity Scale Score = 9). The in-hospital trauma fatality rate was low in both populations and not significantly affected by the intervention. The level of post-operative infections was reduced from 22% to 10.3% during the intervention (95% confidence interval for difference 2.8–20.2%). The trainees' selfrating of skills (Visual Analogue Scale) before and after the training indicated a significantly better coping capacity.Conclusions:Where the rural hospital is an integral part of a prehospital trauma system, systematic training of non-doctors improves the quality of trauma surgery. Initial efforts to improve trauma management in low-income countries should focus on the district hospital.

Severe wartime injuries often require microsurgical reconstruction or pedicle flap transfer. The aim of the study is to explore if such reconstructive surgery can be performed under low-resource conditions in a rural area.A clinical intervention study was performed at rural hospital in a war scenario in the Balkans.Thirty-four patients underwent microsurgical postinjury reconstructions for land mine or blast injuries. Five different types of flaps were used. Three patients developed postoperative complications and was reoperated (8.3%, 95% CI 1.8-22.5%).The actual intervention demonstrates that skilled surgical teams can perform advanced reconstructive surgery in low-resource settings. The experience is not only relevant for wartime scenarios, but also in civilian trauma where decentralization of microsurgical service may be feasible.

Of all deaths from injury, 90% occur in low- and middle-income countries, and most of the injured die before reaching a hospital. We have previously shown that a rural trauma system in Northern Iraq significantly reduced mortality in victims of mines and war injuries. In this follow-up study, we evaluated the adaptation and maturation of the system to changing injury patterns, focusing on mortality, time intervals from injury to medical help, and treatment effect on the physiologic impact of injuries.Approximately 6,000 first responders and 88 paramedics were trained in Northern Iraq from 1996 to 2004 and treated 2,349 victims. All patients were prospectively registered with monitoring of time intervals, interventions performed, prehospital treatment effect, and mortality.Injury pattern changed markedly during the study period, with penetrating injuries decreasing from 91% to 15%. Mortality in victims of mines and war injuries (n = 919) decreased from 28.7% to 9.4% (p = 0.001), as did the time interval from injury to first medical help, from 2.4 hours to 0.6 hours (p = 0.002). The prehospital treatment effect improved significantly in the later part of the study period compared with the first years (p0.0005). Improvement was maintained in new injury groups. Retention of paramedics in the program was 72% after 8 years.This low-tech prehospital emergency system designed for dealing with penetrating trauma matured by reducing time to first medical help and by improving physiologic parameters after prehospital treatment during the 8-year study period. The program adapted to changing injury patterns without compromising results.

Most programs to reduce maternity deaths focus on hospital performance and general obstetric protocols. In communities where most mothers deliver at home, such strategies will not reduce avoidable deaths. The key concept in the actual intervention is to regard deliveries in poor rural communities as a trauma and to merge midwives and traditional birth attendants (TBAs) with an already existing and successful rural trauma rescue system. A total of 256 Cambodian careproviders, 41 health center midwives and paramedics, plus surgical teams at local hospitals were trained over a 2 year period. After completing the training program, the participants themselves rated their skills, confidence, and quality of team work by Visual Analog Scale measurement. The results demonstrate significant improvement, both for the TBAs and the certified midwives. The intervention results so far indicate that delivery life support training to rural careproviders increases their capacity to cope with emergency obstetric cases.

Quantitative studies indicate that one-third of trauma victims in malaria endemic areas of Cambodia develop postinjury malaria. The main aim of this study was to assess the medical significance of the complication. All local doctors with trauma care surgical experience in the Battambang Province of Cambodia were interviewed regarding their experiences with postinjury malaria (n = 18). The qualitative data were processed according to the Editing Style Analysis method. In the study area, postinjury malaria has been a well-known complication to trauma doctors for years. Local doctors claim that the complication is more common in severe as compared to moderate trauma. The complication is reported to adversely affect the general condition of trauma patients, increasing the risk of wound infections, and delaying postoperative recovery. It was found that the informants draw exclusively on personal clinical experience regarding this clinical knowledge, asserting that postinjury malaria is not taught at local medical schools. The study indicated that post-injury malaria is a significant complication to trauma where falciparum malaria is endemic. The knowledge of postinjury malaria in the study area seemed to be non-institutional; the informants' assessments were exclusively based on their personal clinical experience.

Objective:To study the rate of prehospital mortality before establishment of a rescue system for victims of land-mines in Iran.Method:Survey at rural clinics in mine-affected areas, and retrospective review of public patient records.Results:A total of 36.4% of casualties from land-mines in the study area died during the period of 1989–1999. The mortality seems highest in those victims who were torso injured.Conclusion:The mortality rate from accidents involving land-mines in the study area was high. Most fatalities seemingly occurred in the prehospital setting.

The aims of the study were to study chronic pain in land mine accident survivors, and to study the impact of trauma and trauma care parameters on chronic pain. The level of chronic pain was registered (patient-rated and by clinical examination) in 57 severely injured adult land mine accident survivors in Cambodia and Northern Iraq more than one year after the accident. As all study patients had been managed by a standardized trauma system, we could assess the impact of injury severity and primary trauma care on chronic pain. 64% of the study patients (n=36) had chronic pain syndromes (non-significant difference between the two countries). 68% of the amputees (19 out of 28) had phantom limb pain. Pre-injury trauma exposure, the severity of the actual trauma, and the quality of trauma care had no impact on end point chronic pain. In 85% of cases (n=48), the economic standing of the patients’ family had deteriorated after the accident. Patient-rated loss of income correlated with the rate of chronic pain syndromes.

Objective:To study the effects of early, advanced prehospital life support on the survival rate of war casualties during the battle of Jalalabad, Afghanistan from 1989–1992.Method:The outcomes of simple trauma care administered from 1989–1990 were compared to the outcomes of advanced trauma care administered from 1991–1992 in the combat zone. The outcomes were measured by the number of deaths at admission to the referral surgical hospitals in Pakistan.Results:A total of 3,890 war casualties were treated in the combat zone by paramedics, and were evacuated through light, forward, field clinics to surgical hospitals in Pakistan. Advanced trauma care that was administered in the combat zone reduced the prehospital mortality rate from 26.1% to 13.6% (95% confidence interval for difference = 9.7–15.4%).Conclusion:In scenarios with protracted evacuation, early and advanced trauma care should be included in the chain of survival. Local paramedics can provide such trauma care with a minimum of resources.

When Syrian-backed troops attacked the city of Tripoli and the surrounding Palestinian refugee camps in November and December 1983, the authors worked in the Palestine Red Crescent Society (PRCS) Hospital in the area. The hospital was situated close to the front line of the battle at all times and the transportation of casualties was therefore short. During the first month of the battle this hospital received approximately 1,500 casualties, and 390 primary and 24 secondary operations were performed. Multiple shrapnel wounds dominated, and high-velocity missile wounds were also frequently seen. The common treatment principles for missile wounds with radical debridement and delayed primary suture, in some cases secondary suture, were followed. Exploratory surgery was carried out in cases of suspected intra-abdominal and vascular injuries. Limited resources made an efficient selection necessary. Surgery under conditions of war is extremely demanding upon resources: equipment and personnel. By leaving minor debridements and a large amount of the emergency treatment to experienced nurses, a high capacity could be maintained.

A prospective study was carried out of the health effects and sustainability of a low-cost trauma training program for non-graduate village healthcare workers. From 1996 to 1999, a core group of 44 health workers from mine-infested rural communities in Cambodia and Northern Iraq were trained and equipped to deliver low-cost life support to trauma victims. They in turn trained a network of 2800 layman village first responders. Training was done in makeshift camps at village level ('Village Universities'). A total of 813 patients were managed by the rural rescue system from 1997 to 1999. The mortality rate for trauma victims decreased from 22.6% in 1997 to 13.7% in 1999 (95% CI for difference 1.8% to 16.0%). Management by village first responders had a significant impact on in-field response times and trauma mortality. The rescue system replicated itself during the study period as an indicator of sustainability. The study showed that after trauma care training at rural makeshift training centers, non-graduate health workers can build efficient and sustainable rural rescue systems.

OBJECTIVE: The aim of this study was to explore the effect of low-cost prehospital trauma systems on trauma outcome in land mine victims and to study prehospital risk indicators for better triage of land mine injuries. METHODS: A 5-year prospective study of the effect of in-field advanced life support provided by local paramedics was conducted in mine-infested areas in North Iraq and Cambodia. RESULTS: After implementation of a rural rescue system, there was a significant reduction in trauma mortality from 26.2% in 1997 to 11.8% in 2001 (95% confidence interval for difference, 5.1%-23.6%). The mortality rate was significantly higher in fragmentation mine victims, 25.2%, as compared with blast mine victims, 5.7% (95% confidence interval for difference, 14.4%-24.6%). The severity of associated fragment injuries in patients with traumatic amputations is a solid risk predictor (area under the curve in receiver operating characteristics plots > 0.9). CONCLUSIONS: Low-cost prehospital trauma systems improve trauma outcome in land mine victims where prehospital transit times are high. The fragment wounds represent the main challenge for trauma care providers. Language: en

BACKGROUND: A five-year prospective study was conducted in North Iraq and Cambodia to test a model for rural prehospital trauma systems in low-income countries. RESULTS: From 1997 to 2001, 135 local paramedics and 5,200 lay First Responders were trained to provide in-field trauma care. The study population comprised 1,061 trauma victims with mean evacuation time 5.7 hours. The trauma mortality rate was reduced from pre-intervention level at 40% to 14.9% over the study period (95% CI for difference 17.2-33.0%). There was a reduction in trauma deaths from 23.9% in 1997 to 8.8% in 2001 (95% CI for difference 7.8-22.4%), and a corresponding significant improvement of treatment effect by year. The rate of infectious complications remained at 21.5 percent throughout the study period. CONCLUSION: Low-cost rural trauma systems have a significant impact on trauma mortality in low-income countries.