Bystander intervention is associated with reduced early mortality among injury victims in Cameroon.

Despite high injury mortality rates, Cameroon currently lacks a formal prehospital care system. In other sub-Saharan African low and middle-income countries, Lay First Responder (LFR) programs have trained non-medical professionals with high work-related exposure to injury in principles of basic trauma care. To develop a context-appropriate LFR program in Cameroon, we used trauma registry data to understand current layperson bystander involvement in prehospital care and explore associations between current non-formally trained bystander-provided prehospital care and clinical outcomes. The Cameroon Trauma Registry (CTR) is a longitudinal, prospective, multisite trauma registry cohort capturing data on injured patients presenting to four hospitals in Cameroon. We assessed prevalence and patterns of prehospital scene care among all patients enrolled the CTR in 2020. Associations between scene care, clinical status at presentation, and outcomes were tested using univariate and multivariate logistic regression. Injury severity was measured using the abbreviated injury score. Data were analyzed using Stata17. Of 2212 injured patients, 455 (21%) received prehospital care (PC) and 1699 (77%) did not receive care (NPC). Over 90% (424) of prehospital care was provided by persons without formal medical training. PC patients were more severely injured (p<0.001), had markers of increased socioeconomic status (p = 0.01), and longer transport distances (p<0.001) compared to NPC patients. Despite increased severity of injury, patients who received PC were more likely to present with a palpable pulse (OR = 6.2, p = 0.02). Multivariate logistic regression adjusted for injury severity, socioeconomic status and travel distance found PC to be associated with reduced emergency department mortality (OR = 0.14, p<0.0001). Although prehospital injury care in Cameroon is rarely performed and is provided almost entirely by persons without formal medical training, prehospital intervention is associated with increased early survival after injury. Implementation of LFR training to strengthen the frequency and quality of prehospital care has considerable potential to improve trauma survival.

Financing and cost-effectiveness of emergency medical services in low- and middle-income countries.

In 2023, the 76th World Health Assembly declared coordinated emergency, critical, and operative care services fundamental for comprehensive universal health coverage in low- and middle-income countries. With increasing mortality from noncommunicable diseases, an organized emergency care system has the capacity to treat a variety of conditions with a common set of resources, optimizing per-unit cost efficiency by applying economies of scope and increasing cost-effectiveness. However, the financing and cost-effectiveness of emergency medical services remain poorly understood despite affordability and financial barriers comprising some of the most significant obstacles to development. Cost-effectiveness analyses generate incremental cost-effectiveness ratios for comparison against per-capita gross domestic product thresholds to determine cost-effectiveness, promoted by the World Health Organization's Choosing Interventions that are Cost-Effective program. Incremental cost-effectiveness ratios may be used as context-specific indicators of value alongside budget impact and feasibility considerations. Currently, there are few high-quality cost-effectiveness studies of emergency care in low- and middle-income countries, demonstrating significant methodologic heterogeneity, little geographic diversity, neglecting descriptions of assumptions used in cost-effectiveness calculations and comparators used, and lacking incremental cost-effectiveness ratios for comparison. The assessment of emergency care cost-effectiveness is challenging, given the significant breadth of conditions encountered and difficulty in projecting subsequent impact. Without improved epidemiologic surveillance and data-collection infrastructure, data inputs for cost-effectiveness calculations will remain limited. Future efforts should practice standard cost-effectiveness methodologies to permit comparison of incremental cost-effectiveness ratios across interventions and settings while incorporating trauma registry data to longitudinally track patient outcomes over sufficient time horizons to determine impact. New indices that expand the scope of analysis to capture broader secondary impacts of emergency care for future cost-effectiveness studies are needed. In this article, we summarize the key steps for economic evaluations for prehospital care systems and recommend considerations for future prehospital emergency care cost-effectiveness analyses, determining the optimal structure for financing mechanisms well-suited to resource-limited settings are critical for future investigation.

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.

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.

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.

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.

INTRODUCTION: In 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 METHODS: We 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." RESULTS: In 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. CONCLUSION: LFR 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.

Is "memory-for-when" universal? Group and individual variability in temporal position memory for words, faces, and classrooms.

Many contemporary theories of memory assume that everyone automatically stores temporal contextual information about all types of encountered information, yet most studies on this topic have used words and ignored individual differences. Five experiments accumulated evidence that explicit storage of temporal context information does not appear to occur automatically for all people and types of memoranda. We collected judgments of temporal position (memory-for-when) for words (Experiments 1 & 3), faces (Experiments 2A, 3, 4, and 5), and classrooms (Experiments 2B & 3). At the group level, for each of these memoranda memory-for-when was sensitive to the original input position and showed a temporal primacy effect reflecting better memory for position for items near the beginning of the list, indicating some automatic storage of temporal context information. However, memory-for-when was significantly better for words than classrooms, with faces in the middle. Moreover, individuals varied dramatically in their ability to indicate memory-for-when, especially for classrooms where many people performed at or near chance. Taken together, the data suggest that explicit memory-for-when may be dissociable from the more implicit use of temporal contextual information that is theorised to occur during free recall.

Prehospital hemorrhage management in low- and middle-income countries: A scoping review.

INTRODUCTION: Low- and middle-income countries (LMICs) account for 90% of deaths due to injury, largely due to hemorrhage. The increased hemorrhage mortality burden in LMICs is exacerbated by absent or ineffective prehospital care. Hemorrhage management (HM) is an essential component of prehospital care in LMICs, yet current practices for prehospital HM and outcomes from first responder HM training have yet to be summarized. METHODS: This review describes the current literature on prehospital HM and the impact of first responder HM training in LMICs. Articles published between January 2000 and January 2023 were identified using PMC, MEDLINE, and Scopus databases following PRISMA-ScR guidelines. Inclusion criteria spanned first responder training programs delivering prehospital care for HM. Relevant articles were assessed for quality using the Newcastle-Ottawa scale. RESULTS: Of the initial 994 articles, 20 met inclusion criteria representing 16 countries. Studies included randomized control trials, cohort studies, case control studies, reviews, and epidemiological studies. Basic HM curricula were found in 15 studies and advanced HM curricula were found in six studies. Traumatic hemorrhage was indicated in 17 studies while obstetric hemorrhage was indicated in three studies. First responders indicated HM use in 55%-76% of encounters, the most frequent skill they reported using. Mean improvements in HM knowledge acquisition post-course ranged from 23 to 58 percentage points following training for pressure and elevation, gauze application, and tourniquet application. CONCLUSIONS: Our study summarizes the current literature on prehospital HM in LMICs pertaining to epidemiology, interventions, and outcomes. HM resources should be a priority for further development.

Evaluating a digital hybrid training-of-trainers (TOT) approach for lay first responder trauma education in urban Nigeria during the COVID-19 pandemic.

INTRODUCTION: Road traffic injuries (RTIs) are the largest contributor to the global burden of injury, and in 2016 were among the five leading causes of global disability-adjusted life years (DALYs). In regions with limited emergency medical services (EMS), training lay first responders (LFRs) has been shown to increase availability of prehospital care for RTIs, but sustainable mechanisms to scale these programs remain unstudied. METHODS: Using a training of trainers (TOT) model, a 5.5-h LFR training program was launched in Lagos, Nigeria. The course was taught in a hybrid fashion with primary didactics using videoconferencing software and practical breakout sessions in-person concurrently. Thirty TOTs proceeded to train 350 transportation providers as LFRs over one month. A 23-question, pre- and post-assessment was administered digitally to assess knowledge acquisition. Participants responded to a five-point Likert survey assessing instruction quality and post-course confidence. RESULTS: TOTs scored a median of 56.5 % (IQR:43.5 %,71.7 %) and 91.3 % (IQR:88.0 %,95.7 %) on the pre- and post-assessments, respectively, with bleeding control scores increasing most (+69.4 %). LFR course trainees scored a median of 34.8 % (IQR: 26.0 %, 43.5 %) and 73.9 % (IQR: 65.2 %, 82.6 %) on the pre- and post-assessments respectively, with airway and breathing increasing the most (+48.6 %). All score increases were statistically significant with p < 0.001. All 30 TOT trainers instructed at least one training session after their initial session. LFR participants' rated confidence in first aid skills went from 3/5 (IQR 3, 4) pre-course to 5/5 (IQR:5,5) post-course, and in emergency transportation it went from 4/5 (IQR:3, 4) to 5/5 (IQR:5, 5), (p < 0.001). LFR course participants rated the quality of education content and TOT instructors to be 5/5 (IQR:5,5). 144 responders provided emergency care in the six-months following training for a total of 351 interventions. Active responders provided a median of 2 (IQR:1,3) interventions. CONCLUSIONS: This is the first time that a digital hybrid instruction for first responder trainers in low- and middle-income countries has been investigated. Our findings demonstrate negligible attrition, high educational quality ratings, equally effective knowledge acquisition to that of prior in-person courses, and high post-training skill usage. Future work will examine the cost-effectiveness of the training of LFRs and the effect of LFRs on trauma outcomes.

Oxidation of Sulphur pollutants in model and real fuels using hydrodynamic cavitation.

Hydrodynamic Cavitation (HC) offers an attractive platform for intensifying oxidative desulphurization of fuels. In the first part of this work, we present new results on oxidising single ring thiophene in a model fuel over the extended range of volume fraction of organic phase from 2.5 to 80 v/v %. We also present influence of type and scale of HC device on performance of oxidative desulphurization. Further experiments revealed that oxidising radicals generated in-situ by HC alone were not able to oxidise dual ring thiophenes. External catalyst (formic acid) and oxidising agents (hydrogen peroxide, H2O2) were therefore used with HC. Based on our prior work with acoustic cavitation (AC), the volumetric ratios for H2O2 and formic acid were identified as 0.95 v/v % and 6.25 v/v % respectively. The data of oxidation of dual ring thiophenes with n-dodecane and n-hexane as model fuels and typical transport fuels (diesel, kerosene, and petrol) using these oxidant and catalyst is presented. The observed performance with HC was compared with results obtained from a stirred tank and AC set-up. The presented data indicates that HC is able to intensify oxidation of sulphur species. The presented results provide a sound basis for further developments on HC based oxidative desulphurization processes.

Updating and pre-existing semantic associations: testing can enhance or impair new learning.

We often need to update what we have learned, building on older information by adding newer information. When updating, is it better to review the older information by retrieving it (testing) or restudying it? In other words, do tests result in enhanced updating or impaired updating compared to restudying? Past research has obtained divergent conclusions to this question. The present study used a paired associates updating paradigm in which participants studied a cue and the older response (A-B). They later reviewed the older response by restudying (A-B) or testing (A-?; A-B) and immediately after learned a newer response (-D) that updated the original pair into a trio (A-B-D). In eight experiments, we demonstrated that different patterns of pre-existing semantic associations between the cue, older response, and newer response resulted in all possible outcomes: test enhanced new learning, test impaired new learning, and no difference. The results were most consistent with a family of updating theories that propose the metacognitive processes that occur after reviewing determine whether testing enhances, impairs, or has no impact on new learning. The results suggest that theories should consider the impact of the newer response in updating in addition to performance on the initial test.

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

INTRODUCTION: The 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 METHODS: We 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." RESULTS: Median 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). CONCLUSION: LFRs 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.

People sometimes remember to forget: Strategic retrieval from the list before last enables directed forgetting of the most recent information.

List-method directed forgetting usually involves asking people to study a list, followed by a cue to forget it, and then studying a second list. Prior work suggests that List 2 encoding is necessary for directed forgetting to occur, but recent studies have found that moving the forget cue from List 1 to List 2 allows people to selectively forget List 2. These results were attributed to an inhibitory mechanism. In four experiments, we aimed to replicate these findings and provide an alternative explanation based on the list-before-the-last paradigm. We propose that in the forget condition, participants may strategically retrieve List 1 in response to the forget cue, contributing to selective forgetting. Previous research suggests that explicit retrieval of earlier-leaned information causes a contextual shift, resulting in forgetting of target information. Verbal reports from Experiments 1 and 2 indicated that participants often covertly select a retrieval strategy to forget the most recent list. In Experiment 3, explicit instructions to retrieve resulted in significant forgetting. Directly manipulating forgetting strategy between participants in Experiment 4 suggested that retrieval may be one of several effective mechanisms to forget recently-encountered information. In the retrieval conditions, the data support our claim that in the absence of explicit postcue encoding, people can strategically retrieve earlier-learned information to forget. This novel forgetting mechanism is probably also used outside of the laboratory to "roll back" memory for incorrect information. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Removal of single and dual ring thiophene's from dodecane using cavitation based processes.

Utilising cavitation for enhancing oxidative desulphurization has been investigated for nearly-two decades with recent investigations shifting focus from low-capacity acoustic cavitation (AC) to scalable hydrodynamic cavitation (HC). This work focuses on developing a viable means for removing thiophene's from fuels. In the first phase of this work, use of vortex based HC devices for removal of single and dual ring thiophenes from dodecane was investigated. HC was shown to be able to remove single ring thiophene from dodecane without using any external catalyst or additives. However, in absence of catalyst or additives, it was not possible to remove dual ring thiophenes such as dibenzothiophene using HC. Therefore, in the second phase of this work, various strategies based on use of catalyst or additives to augment cavitation based process were investigated. AC based experiments were opted for shortlisting suitable catalysts and additives for intensifying cavitation based processes. The influence of using oxidant (H2O2) and carboxylic acid catalysts on efficacy of removal of dual ring thiophenes is presented. Several conditions were tested, and the optimal volumetric ratios of 0.95 v/v % H2O2 and 6.25 v/v % HCOOH was identified and utilised throughout the remainder of the study. Regeneration of extractant which accumulates oxidised sulphur species from dodecane was also investigated using AC. The additives and process conditions reported in this work are useful for enhancing desulphurization performance.

Comparing Ugandan motorcycle taxi driver estimations of injury incidence to District-level injury surveillance data as a proxy to determine factors influencing risk perception.

Introduction: road traffic incidents (RTIs) are a leading cause of death among young people, disproportionately affecting low- and middle-income countries (LMICs), where motorcycle taxis disproportionately contribute to injury. Though driver behavior has been identified as the most important factor in RTIs, the factors that influence risk perception, which affect driver behavior, have not been well-studied in LMICs and may inform future strategies to limit risky behavior. Methods: Ugandan motorcycle taxi drivers (n=117) were surveyed on personal characteristics and experiences, ranking apparent risk of select injury conditions. Rankings were then compared against the actual frequency of corresponding District-level injury surveillance data for the same injury conditions to investigate the accuracy of respondent risk perception. Personal characteristics were then regressed against the perceived risk of certain injury classification rankings to investigate possible factors influencing rankings. Results: over 26 months, 21,253 injury-related events were recorded in Iganga District, of which 7,424 patient encounters (34.93%) were related to RTI. Ugandan motorcycle taxi drivers tended to over-estimate the risk associated with their profession, but correctly classified the three most common injuries. Regression analyses revealed personal characteristics including personal exposure to RTIs (B=0.037, t=2.035, p=0.044) and years of experience (B=0.026, t=1.828, p=0.070) predicted perceived risk. Conclusion: Ugandan motorcycle taxi drivers accurately predict the risks associated with their profession. The perception of these risks may be affected by years of experience and previously witnessed RTIs. Further empirical investigation is required to document all key motives and perspectives of drivers as factors that influence risk perception and subsequent behavior in LMICs and may inform future strategies to limit risky behavior.

Item method directed forgetting occurs independently of borderline personality traits, even for borderline-salient items.

Clinical populations sometimes demonstrate difficulties forgetting stimuli related to their trauma-related disorder, perhaps because their intense personal connection to these stimuli produce deficits in the inhibitory control abilities necessary for forgetting. The present work examined this possibility for people who have high levels of traits implicated in borderline personality disorder (BPD). In two well-powered studies, we found no evidence for deficits in forgetting specific to BPD traits, even for people with clinically significant levels of the traits, contrary to previous studies. The present experiments updated the designs from earlier experiments to employ the most contemporary methods to examine directed forgetting recommended by recent reviews. With these improved methods, Study 1 found that participants showed significant directed forgetting for BPD-related words independent of their level of BPD traits, perhaps because the BPD-related words were so strongly associated with one another. Study 2 found that when we removed the strong relatedness between the stimuli, forgetting of BPD-relevant words was significant and did not interact with BPD symptomology. We concluded that in contrast to people with PTSD who show specific inhibitory deficits for trauma-related works, people with BPD show normal, intact inhibitory control even for words that they should find threatening.

Prehospital Airway Management for Trauma Patients by First Responders in Six Sub-Saharan African Countries and Five Other Low- and Middle-Income Countries: A Scoping Review.

The global injury burden disproportionately affecting low- and middle-income countries (LMICs) is exacerbated by a lack of robust emergency medical services. Though airway management (AM) is an essential component of prehospital emergency care, the current standard of prehospital AM training and resources for first responders in LMICs is unknown. This scoping review includes articles published between January 2000 and June 2021, identified using PMC, MEDLINE, and SCOPUS databases, following PRISMA-ScR guidelines. Inclusion criteria spanned programs training formal or informal prehospital first responders. Included articles were assessed for quality using the Newcastle-Ottawa scale. Relevant characteristics were extracted by multiple authors to assess prehospital AM training. Of the initial 713 articles, 17 met inclusion criteria, representing 11 countries. Basic AM curricula were found in 11 studies and advanced AM curricula were found in nine studies. 35.3% (n = 6) of first responder programs provided no equipment to basic life support (BLS) AM training participants, reporting a median cost of $7.00USD per responder trained. Median frequency of prehospital AM intervention was reported in 31.0% (IQR: 6.0, 50.0) of patient encounters (advanced life support trainees: 12.1%, BLS trainees: 32.0%). In three studies, adverse event frequencies during intubation occurred with a median frequency of 22.0% (IQR: 21.0, 22.0). The training deficit in advanced AM interventions in LMICs suggests BLS AM courses should be prioritized, especially in sub-Saharan Africa. Prehospital AM resources are sparse and should be a priority for future development.

Evaluating a novel, low-cost technique for cervical-spine immobilization for application in resource-limited LMICs: a non-inferiority trial.

STUDY DESIGN: Non-inferiority trial. OBJECTIVE: Limited cervical spinal (c-spine) immobilization in resource-limited settings of LMICs suggests alternatives are necessary for patients with traumatic injuries. We propose a novel method of c-spine immobilization using folded towels. SETTING: Washington University in St. Louis. METHODS: Using non-inferiority trial design, thirty healthy patients (median age = 22) were enrolled to test the efficacy of folded towels in comparison with rigid cervical collars, foam neck braces, and no immobilization. We measured cervical range of motion (CROM) in six cardinal directions in seated and supine positions. A weighted composite score (CS) was generated to compare immobilization methods. A preserved fraction of 75% was determined for non-inferiority, corresponding to the difference between the median values for CROM between control (no immobilization) and c-collar states. RESULTS: C-collars reduce median CROM in six cardinal directions in seated and supine positions by an average of -36.83° seated (-17.75° supine) vs. no immobilization. Folded towels and foam neck braces reduced CROM by -27° seated (-16.75° supine) and -14.25° seated (-9.5° supine), respectively. Compared to a 25% non-inferiority margin (permitting an average 9.21° of cervical movement across six cardinal directions), the CS determined folded towels are non-inferior (CSseated = 0.89, CSsupine = 0.47). Foam neck braces are inferior (CSseated = 2.35, CSsupine = 2.10). CS > 1 surpassed the non-inferiority margin and were deemed inferior. CONCLUSIONS: Folded towels are a non-inferior means of immobilizing c-spine in extension and rotation, but not flexion, vs. c-collars. We propose folded towels could be trialed in combination with backboards to deliver affordable and effective prehospital TSCI management in resource-limited settings.

Identifying a 'super-responder' phenomenon in three African countries: Implications for prehospital emergency care training.

BACKGROUND: Few countries in Sub-Saharan Africa have robust emergency medical services (EMS). The WHO recommends training lay first responders (LFRs) as the first step toward EMS development while Disease Control Priorities (DCP) suggests training 0.5%-1% of a population for adequate emergency catchment. After launching three LFR programs in Africa, this study investigated subsequent skill usage and conducted demographic analyses to inform future recruitment of high-responding LFRs. METHODS: Demographic characteristics and individual LFR intervention frequencies were collected from a pooled sample of 887 of 1,291 total LFRs (68.7%) trained across programs launched in a staggered fashion between 2016-2019 in Uganda, Chad, and Sierra Leone. A Kruskal-Wallis Rank-Sum test assessed between-group differences among demographics in each location. Spearman's r was used to determine the relationship between response frequency and LFR characteristics. RESULTS: Most LFRs trained did not use skills post-training (median LFR interventions=0.0 interventions/year [IQR:0.0,5.0]). Right-skewed intervention frequency distributions demonstrate high-responding outlier responder groups do exist in all locations (p<0.0001). Median LFR interventions of the top quartile of these active LFRs ("super-responders") was 26.0 interventions/year (IQR:16.7,35.0). "Super-responders" witnessed more road traffic injuries (RTIs) prior to training (p=0.033). LFRs who never responded were significantly younger (p=0.0020). Significant correlations were demonstrated between pooled RTIs witnessed and intervention frequency (r=0.13, p=0.032) and age and intervention frequency in Sierra Leone (r=-0.15, p=0.019). CONCLUSION: Current DCP-recommended training of 0.5-1% of a given population for adequate emergency catchment may be an inefficient means of building emergency care capacity. Recruiting "super-responders" with select characteristics may achieve similar coverage while conserving valuable training resources in resource-limited African settings.

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

BACKGROUND: 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. MATERIALS/METHODS: 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." RESULTS: 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). CONCLUSION: 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.