Prehospital trauma system in a low-income country: system maturation and adaptation during 8 years.

BACKGROUND: 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. METHODS: 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. RESULTS: 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 (p < 0.0005). Improvement was maintained in new injury groups. Retention of paramedics in the program was 72% after 8 years. CONCLUSIONS: 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.

Life or death. The social impact of paramedics and first responders in landmine-infested villages in northern Iraq.

INTRODUCTION: Landmines are indiscriminate weapons that mainly injure poor populations in the developing world. Pre-hospital treatment by village-based paramedics and first responders has reduced mortality, but little is known about the social impact of paramedic and first responder training in villages. The aim of this study was to understand how villagers in socially deprived, mine-infested villages experience the establishment of paramedic and first responder chains of survival. METHODS: The study used focus-group interviews conducted in four villages in northern Iraq, to explore villagers' perceptions of the impact of paramedic and first responder training. The material was analyzed using grounded theory, with the main category identified entitled 'life or death', with three subcategories: 'living on the edge', 'demanding equal rights', and 'adapting to new needs'. RESULTS: The paramedics were perceived by the villagers as having a large impact on the social life of the village, first as an emergency medical resource, and also as a prerequisite for the villages' continued existence. The system represented one of the few services offered by outside society to villages that lacked health care, schools, electricity, roads, and clean water. Despite an improved economic situation in the larger society, conditions in the villages had deteriorated. Although originally intended as an emergency care system for land mine victims, the system was adapted to include the role of a general medical resource in the villages. This adaptation was perceived as useful by the villagers, and necessary for their continued trust in the system. A prerequisite for this adaptation was that the program coordinator was a villager himself, and that the program deviated from its originally fixed time period. This flexibility depended on very close cooperation between expatriate and local program managers. CONCLUSIONS: Our findings indicate that the paramedic system made a wider impact than just the provision of emergency health care. The program earned trust through a strong local anchor, and by adapting to the needs of the population served.