Prehospital Trauma Care in Kampala, Uganda and the Effectiveness of a Pilot Training Program for Lay

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Prehospital Trauma Care in Kampala, Uganda and
the Effectiveness of a Pilot Training Program
for Lay First-Responders

• Jayaraman S1, Ozgediz D2, Lipnick M3, Caldwell
  N1, Miyamoto J1, Mabweijano JR4, Mijumbi C4, Hsia
  R1, Dicker R1
• 1 University of California, San Francisco, US
• 2 Hospital for Sick Children, Toronto, Canada
• 3 Brigham Womens Hospital, Boston, US
• 4 Mulago Hospital and Makerere University,
  Kampala, Uganda

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Trauma in Low Middle Income Countries

• 1-2 million avertable deaths/year1
• 90 of all deaths from road traffic injuries2
• gt80 of all injury deaths are prehospital3
• Role of lay first-responders in countries without
  formal EMS
• Endorsed by WHO, World Bank
• Iraq, Cambodia, Ghana

1 3 Mock, J. Trauma, 1998 2 WHO 1996
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Context

• UCSF Mulago Hospital
• 5 year collaboration
• Uganda
• Former British Colony
• Population 30 million
• Annual Income per capita 3401
• Common Languages
• English
• Luganda

Photo from www.sbc.melb.catholic.edu.au
1 World Bank, 2008
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Urban Kampala
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Streets of Kampala
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UCSF-Mulago Collaboration

• Trauma care is a major unmet need
• There is NO formal prehospital emergency system
  in Kampala

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Surgeons Pre-hospital Trauma Care?

• 1200 bed government hospital
• Only 24 hour ER in the city
• No ER physicians
• ER medical surgical halves
• Surgical side 2 general surgeons
• Aware of impact of no prehospital care

Mulago Hospital
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EMS in Kampala

• Current care
• Police and Minibus Taxi drivers (on the road)
• Local Council officials (near the home)
• Injured patients arrive via
• private car
• motorcycle
• minibus taxi
• police vehicle
• foot
• lt5 arrive by ambulance

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A Police Vehicle Transports an Injured Victim to
Mulago
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Challenges to Emergency Care in Kampala

• Scene
• Police victims cannot go to medical facilities
  until after crash investigation
• Immediate Care
• Police have no access to first-aid kits
• Police will not handle patients without gloves
• Many patients arrive at Mulago with open,
  bleeding wounds
• Transport
• No airway protection the unconscious are brought
  supine
• No back board or c-collar available

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Hypothesis

• Lay people can learn the basic principles of
  prehospital trauma care in a one day,
  context-appropriate course

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Methods

• Recruited 307 lay people
• Police officers
• Taxi drivers and conductors
• Local Council officials

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Design

• Project designed with participation of multiple
  local stakeholders
• Once requisite IRB approvals were obtained
• Baseline Survey 307 individual interviews
• Training Program included
• Modified Basic First-aid Course
• Free First-Aid Kit
• Fund of Knowledge tests

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Course Content

• Scene management
• Universal precautions
• Basic airway skills lateral decubitus position
• External compression for hemorrhage control
• Immobilization of fractures
• Safe patient transfer
• Safe transport to hospital
• Triage

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Course Design

• Context appropriate
• Resource constrained
• High infectious disease prevalence
• Example No field CPR
• Hands-on
• Participants NO prior training expected
• Literacy barriers
• Reading materials not likely to be very effective
• Two languages
• Police English
• All others Luganda

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Study Tools

• Baseline survey
• Pre and post training fund of knowledge tests
• Designed and validated
• English Luganda
• Pilot tested twice, in both languages before use

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First-aid Kit

• A basic kit provided to each trainee
• Made of locally available materials
• duffel bag
• reusable tarpaulin for use as a modified
  stretcher
• bleach to clean the tarpaulin
• gloves
• gauze
• cotton
• bandages triangular and crepe
• tape
• cardboard for use as splints
• Kit cost 16
• Commercial kits 62.50 -187.50

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Arm Band
Vehicle Placard
ID Card
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Learning how to splint during the course
Injured victim at Mulago - treated by a study
trainee
Police officer with first-aid kit
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Results

• 307 lay people participated
• 177 Police officers
• 92 Minibus Taxi drivers Conductors
• 38 Local Council Officials

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Survey Results Current Prehospital Care

• 19 traumatic emergencies/trainee over 6 months
  (median11)
• 39 encountered gt1 trauma deaths
• (of n236)
• Most common traumatic emergencies
• Road crashes (90)
• Assault (67)
• Burns (45)

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Results Fund of Knowledge tests

• Training Course improved Fund of Knowledge
• Mean Score
• Baseline 45
• Post-training 86 (paired t test,
  plt0.0001)
• Scores improved in every skill area
• Greatest improvements (plt0.0001)
• Use of lateral decubitus position (28 -gt 96)
• Need for careful transportation (31 -gt 87)

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6 Months
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6 Months
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Limitations

• Small pilot study
• 307 trainees -- 1.2 million population
• Measured changes in fund of knowledge not
  clinical outcomes

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Future Directions

• Follow-up to evaluate
• Frequency of skill use
• Use of first-aid kit
• Retention of Knowledge
• Local, Regional International Dissemination
• Collaborate with police training schools
• train the trainers
• sustainability

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Conclusions

• A one day, context-appropriate prehospital trauma
  course improves the fund of knowledge of lay
  trainees

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Policy Implications

• Training lay first-responders should be a key
  policy priority in Uganda
• Lay people in Kampala
• see many emergencies
• provide the bulk of prehospital care
• have little organized support
• can learn basic prehospital trauma care
• Training lay first-responders can
• be an effective first step in developing a formal
  emergency system for Kampala, Uganda
• build on the informal existing system of care

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Acknowledgments

• Uganda
• Mulago Hospital and Makerere University
• Ministry of Health
• The Injury Control Center
• The Red Cross
• The Kampala Police Department
• The Taxi Operators and Drivers Association
• The Kampala District Local Government
• The Kampala City Council Department of Health
• US/UK
• Hellman Family Foundation
• The Laura Case Trust
• UCSF