The Village University- save lives, save limbs

Ole-Kristian Losvik – losvik@gmail.com

Tromsoe Mine Victim Resource Center

Soria Moria 13.Sept 2011

Kongsberg model. Photo: US NavyTromsø model. Photo: TMC.

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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…

• losvik@gmail.com

• Thanks to NorwegianMinistry of Foreign Affairs for supportthrough 15 years!

MFA

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