Transportation and equipment needs for emergency medical services development in low- and middle-income countries.

Prehospital emergency medical services play a vital role in reducing mortality and disease burden in low- and middle-income countries. However, the availability of adequate prehospital emergency care remains a significant challenge in many resource-limited communities, with over 91% of the African population lacking access to sufficient emergency medical services. This commentary aims to highlight the critical components of transportation infrastructure and medical supply chain challenges for emergency medical service development and propose potential solutions for future study. Transportation is a key factor influencing prehospital mortality, yet many low- and middle-income countries face issues related to timely prehospital transportation, with patients often relying on family members or private vehicles for transportation, leading to delays in reaching healthcare facilities due to poor road infrastructure. Dysfunctional and inadequate vehicles are also common barriers to timely care. Response times and transport times often exceed high-income standards, with some rural areas experiencing total prehospital time, defined as the time of injury to arrival at definitive care, exceeding 24 hours. To address these transportation challenges, some low- and middle-income countries have developed tier-1 emergency medical services programs that use existing transportation infrastructure and involve lay first responders using motorized and non-motorized vehicles. These programs prioritize rapid transportation over advanced on-scene intervention, potentially providing faster response times. A combination of tier-1 and tier-2 emergency medical services systems, as seen in some successful examples, allows for early on-scene guidance and resource allocation. In addition to transportation, the availability of medical equipment is crucial for effective prehospital interventions, particularly in tier-2 systems. However, low- and middle-income countries often face shortages of even basic supplies, limiting the scope of care that emergency medical services personnel can provide. Developing tier-2 emergency medical services upon a foundation of tier-1 prehospital care utilizing sustainable local supply chains and common household items for basic care can help alleviate these equipment challenges. The integration of tier-1 and tier-2 systems may offer a promising solution to address resource limitations and improve timely access to emergency care in low- and middle-income countries. Further research and investment are required to explore and implement these solutions, ultimately reducing mortality and enhancing healthcare services in resource-limited communities.

Association of freeze-dried plasma with 24-h mortality among trauma patients at risk for hemorrhage.

BACKGROUND: Blood products form the cornerstone of contemporary hemorrhage control but are limited resources. Freeze-dried plasma (FDP), which contains coagulation factors, is a promising adjunct in hemostatic resuscitation. We explore the association between FDP alone or in combination with other blood products on 24-h mortality. STUDY DESIGN AND METHODS: This is a secondary data analysis from a cross-sectional prospective observational multicenter study of adult trauma patients in the Western Cape of South Africa. We compare mortality among trauma patients at risk of hemorrhage in three treatment groups: Blood Products only, FDP + Blood Products, and FDP only. We apply inverse probability of treatment weighting and fit a multivariable Cox proportional hazards model to assess the hazard of 24-h mortality. RESULTS: Four hundred and forty-eight patients were included, and 55 (12.2%) died within 24 h of hospital arrival. Compared to the Blood Products only group, we found no difference in 24-h mortality for the FDP + Blood Product group (p = .40) and a lower hazard of death for the FDP only group (hazard = 0.38; 95% CI, 0.15-1.00; p = .05). However, sensitivity analyses showed no difference in 24-h mortality across treatments in subgroups with moderate and severe shock, early blood product administration, and accounting for immortal time bias. CONCLUSION: We found insufficient evidence to conclude there is a difference in relative 24-h mortality among trauma patients at risk for hemorrhage who received FDP alone, blood products alone, or blood products with FDP. There may be an adjunctive role for FDP in hemorrhagic shock resuscitation in settings with significantly restricted access to blood products.

Patterns of on-scene and healthcare system trauma deaths in the Western Cape of South Africa.

BACKGROUND: Injuries account for 8% or 4.4 million deaths annually worldwide, with 90% of injury deaths occurring in low- and middle-income countries. Inter-personal violence and road traffic injuries account for most injury deaths in South Africa, with rates among the highest globally. Understanding the location, timing, and factors of trauma deaths can identify opportunities to strengthen care. METHODS: This is a retrospective cross-sectional secondary analysis of trauma deaths from 2021 to 2022 in the Western Cape of South Africa. Healthcare system trauma deaths were identified from a multicenter study paired with a dataset for on-scene (i.e., prior to ambulance or hospital) trauma deaths in the same jurisdictions. We describe locations, timing, injury factors, and cause of death. We assess associations between those factors. RESULTS: There were 2418 deaths, predominantly young men, with most (2274, 94.0%) occurring on-scene. The most frequent mechanism of injury for all deaths was firearms (32.6%), followed by road traffic collisions (17.8%). On-scene deaths (33.2%) were significantly more likely to be injured by firearms compared to healthcare system deaths (23.6%) (p-value <0.01). Most healthcare system deaths within 4-24 h of injury occurred in a hospital emergency center. Among healthcare system decedents, half died in the emergency unit. CONCLUSIONS: We identified a large burden of deaths from interpersonal violence and road traffic collisions, mostly on-scene. In addition to primary prevention, shortening delays to care can improve mortality outcomes especially for deaths occurring within 4-24 h in emergency centers.

The Effect of Prehospital Clinical Trial-Related Procedures on Scene Interval, Cognitive Load, and Error: A Randomized Simulation Study.

INTRODUCTION: Globally, very few settings have undertaken prehospital randomized controlled trials. Given this lack of experience, there is a risk that such trials in these settings may result in protocol deviations, increased prehospital intervals, and increased cognitive load, leading to error. Ultimately, this may affect patient safety and mortality. The aim of this study was to assess the effect of trial-related procedures on simulated scene interval, self-reported cognitive load, medical errors, and time to action. METHODS: This was a prospective simulation study. Using a cross-over design, ten teams of prehospital clinicians were allocated to three separate simulation arms in a random order. Simulations were: (1) Eligibility assessment and administration of freeze-dried plasma (FDP) and a hemoglobin-based oxygen carrier (HBOC), (2) Eligibility assessment and administration of HBOC, (3) Eligibility assessment and standard care. All simulations also required clinical management of hemorrhagic shock. Simulated scene interval, error rates, cognitive load (measured by NASA Task Load Index), and competency in clinical care (assessed using the Simulation Assessment Tool Limiting Assessment Bias (SATLAB)) were measured. Mean differences between simulations with and without trial-related procedures were sought using one-way ANOVA or Kruskal-Wallis test. A p-value of <0.05 within the 95% confidence interval was considered significant. RESULTS: Thirty simulations were undertaken, representing our powered sample size. The mean scene intervals were 00:16:56 for Simulation 1 (FDP and HBOC), 00:17:22 for Simulation 2 (HBOC only), and 00:14:24 for Simulation 3 (standard care). Scene interval did not differ between the groups (p = 0.27). There were also no significant differences in error rates (p = 0.28) or cognitive load (p = 0.67) between the simulation groups. There was no correlation between cognitive load and error rates (r = 0.15, p = 0.42). Competency was achieved in all the assessment criteria for all simulation groups. CONCLUSION: In a simulated environment, eligibility screening, performance of trial-related procedures, and clinical management of patients with hemorrhagic shock can be completed competently by prehospital advanced life support clinicians without delaying transport or emergency care. Future prehospital clinical trials may use a similar approach to help ensure graded and cautious implementation of clinical trial procedures into prehospital emergency care systems.

A 12-month retrospective descriptive analysis of a single helicopter emergency medical service operator in four South African provinces.

Introduction: Helicopter Emergency Medical Services (HEMS) is integrated into modern emergency medical services because of its suggested mortality benefit in certain patient populations, it is an expensive resource and appropriate use/feasibility in low- to middle income countries (LMIC) is highly debated. To maximise benefit, correct patient selection in HEMS is paramount. To achieve this, current practices first need to be described. The study aims to describe a population of patients utilising HEMS in South Africa, in terms of flight data, patient demographics, provisional diagnosis, as well as clinical characteristics and interventions. Methods: A retrospective flight- and patient-chart review were conducted, extracting clinical and mission data of a single aeromedical operator in South Africa, over a 12-month period (July 2017 - June 2018) in Gauteng, Free State, Mpumalanga and North-West provinces. Results: A total of 916 cases were included (203 primary cases, 713 interfacility transport (IFT) cases). Most patients transported were male (n=548, 59.8%) and suffered blunt trauma (n=379, 41.4%). Medical pathology (n=247, 27%) and neonatal transfers (n=184, 20.1%) follows. Flights occurred mainly in daylight hours (n=729, 79.6%) with median mission times of 1-hour 53 minutes (primary missions), and 3 hours 10 minutes (IFT missions). Median on-scene times were 26 minutes (primary missions) and 55 minutes (IFT missions). Almost half were transported with an endotracheal tube (n=428, 46.7%), with a large number receiving no respiratory support (n=414, 45.2%). No patients received fibrinolysis, defibrillation, cardioversion or cardiac pacing. Intravenous fluid therapy (n=867, 94.7%) was almost universal, with common administration of sedation (n=430, 46.9%) and analgesia (n=329, 35.9%). Conclusion: Apart from the lack of universal call-out criteria and response to the high burden of trauma, HEMS seem to fulfil an important critical care transport role. It seems that cardiac pathologies are under-represented in this study and might have an important implication for crew training requirements.

A retrospective descriptive analysis of non-physician-performed prehospital endotracheal intubation practices and performance in South Africa.

INTRODUCTION: Prehospital advanced airway management, including endotracheal intubation (ETI), is one of the most commonly performed advanced life support skills. In South Africa, prehospital ETI is performed by non-physician prehospital providers. This practice has recently come under scrutiny due to lower first pass (FPS) and overall success rates, a high incidence of adverse events (AEs), and limited evidence regarding the impact of ETI on mortality. The aim of this study was to describe non-physician ETI in a South African national sample in terms of patient demographics, indications for intubation, means of intubation and success rates. A secondary aim was to determine what factors were predictive of first pass success. METHODS: This study was a retrospective chart review of prehospital ETIs performed by non-physician prehospital providers, between 01 January 2017 and 31 December 2017. Two national private Emergency Medical Services (EMS) and one provincial public EMS were sampled. Data were analysed descriptively and summarised. Logistic regression was performed to evaluate factors that affect the likelihood of FPS. RESULTS: A total of 926 cases were included. The majority of cases were adults (n = 781, 84.3%) and male (n = 553, 57.6%). The most common pathologies requiring emergency treatment were head injury, including traumatic brain injury (n = 328, 35.4%), followed by cardiac arrest (n = 204, 22.0%). The mean time on scene was 46 minutes (SD = 28.3). The most cited indication for intubation was decreased level of consciousness (n = 515, 55.6%), followed by cardiac arrest (n = 242, 26.9%) and ineffective ventilation (n = 96, 10.4%). Rapid sequence intubation (RSI, n = 344, 37.2%) was the most common approach. The FPS rate was 75.3%, with an overall success rate of 95.7%. Intubation failed in 33 (3.6%) patients. The need for ventilation was inversely associated with FPS (OR = 0.42, 95% CI: 0.20-0.88, p = 0.02); while deep sedation (OR = 0.56, 95% CI: 0.36-0.88, p = 0.13) and no drugs (OR = 0.47, 95% CI: 0.25-0.90, p = 0.02) compared to RSI was less likely to result in FPS. Increased scene time (OR = 0.99, 95% CI: 0.985-0.997, p < 0.01) was inversely associated FPS. CONCLUSION: This is one of the first and largest studies evaluating prehospital ETI in Africa. In this sample of ground-based EMS non-physician ETI, we found success rates similar to those reported in the literature. More research is needed to determine AE rates and the impact of ETI on patient outcome. There is an urgent need to standardise prehospital ETI reporting in South Africa to facilitate future research.

Out-of-hospital cardiac arrests in the city of Cape Town metropole of the Western Cape province of South Africa: a spatio-temporal analysis.

BACKGROUND: The incidence of out-of-hospital cardiac arrest (OHCA) is expected to increase in sub-Saharan Africa along with the incidence of cardiovascular disease. In low-resource settings (LRS), OHCA carries a negligible survival rate. Interventions to improve OHCA survival might not be cost effective for many LRS, and therefore need to be targeted to areas of high incidence. The aim of this study was to describe the temporal and geographic distribution of OHCA in the City of Cape Town, South Africa, and their proximity to percutaneous coronary intervention (PCI) resources. METHODS: In this retrospective study, OHCA data between 1 January and 31 December 2018 were extracted from public and one private emergency medical services in the Western Cape. For temporal analysis, distribution of OHCA according to time of day, day of the week and month of the year were subjected to chi-squared testing. For geospatial analysis, cluster and outlier, and hotspot analyses were performed. Proximity analysis was employed to determine the driving time from OHCA location to the closest PCI-capable facility. RESULTS: A total of 929 patients with OHCA received an emergency medical services response in the City of Cape Town, corresponding to an annual prevalence of 23.2 per 100 000 persons. The distribution of OHCA incidence was not explained by month of the year (p = 0.08) or day of the week (p = 0.67). A statistically significant variation in OHCA incidence was explained by time of day (p < 0.01) with 30% (n = 279) of all OHCAs occurring from 05:00 to 09:59. Geospatial analysis yielded a large area of hotspots (99% confidence interval) over the centre of the metropole, Cape Flats and southern suburbs. The median (interquartile range) driving time from the incident to the closest PCI-capable facility was 10:22 (08:05) minutes. CONCLUSIONS: Incidents of OHCA occurred predominantly at home during the mid-morning, with hotspots around the city centre and residential suburbs of Cape Town. While the incidents occurred close to PCI-capable facilities, some areas remained underserved and access to PCI for OHCA victims may be impossible due to socio-economic factors. With an increase in OHCA incidence expected, it is essential that contextual, cost-effective management interventions be developed and implemented.

The lay descriptors of out-of-hospital cardiac arrest in the Western Cape province, South Africa.

INTRODUCTION: Out-of-Hospital Cardiac Arrest (OHCA) is a time-sensitive emergency requiring prompt identification and emergency care to reduce morbidity and mortality. The first step in managing OHCA is rapid identification by the emergency dispatch centre. Identification of these patients remains challenging in South Africa due to multiple languages and widely differing levels of education. This study aimed to identify the key descriptors (words and phrases) of OHCA used by callers in the Western Cape when contacting the provincial Emergency Medical Services' emergency call centre. METHODOLOGY: Computer-aided dispatch data with a corresponding "patient unresponsive" incident type were drawn for a 12-month period (January-December 2018). Corresponding patient care records were extracted to verify OHCA. The original voice recordings between the caller and emergency call taker at the time of the emergency were extracted and transcribed verbatim. Transcriptions were subjected to inductive, qualitative content analysis to the manifest level. Descriptors of OHCA in isiXhosa, English and Afrikaans calls were coded, categorised, and quantified. RESULTS: A total of 729 confirmed OHCA cases were identified, of which 38 (5.2%) Afrikaans, 24 (3.3%) isiXhosa and a random sample of 50 (6.8%) English calls were transcribed. Following content analysis, five distinct categories were identified. The most prevalent categories were descriptors related to ill health (medical history and suspected diagnosis; 35.5%), level of consciousness (unresponsive; 18.6%) and cardiac activity (pulselessness and suspected death; 17.2%). CONCLUSION: The vast majority of callers within the Western Cape province of South Africa use consistent descriptors across languages when requesting an ambulance for OHCA. Future studies should focus on the development and validation of OHCA recognition algorithms, based on these findings.

Out-of-hospital cardiac arrests in the city of Cape Town, South Africa: a retrospective, descriptive analysis of prehospital patient records.

OBJECTIVES: While prospective epidemiological data for out-of-hospital cardiac arrest (OHCA) exists in many high-income settings, there is a dearth of such data for the African continent. The aim of this study was to describe OHCA in the Cape Town metropole, South Africa. DESIGN: Observational study with a retrospective descriptive design. SETTING: Cape Town metropole, Western Cape province, South Africa. PARTICIPANTS: All patients with OHCA for the period 1 January 2018-31 December 2018 were extracted from public and private emergency medical services (EMS) and described. OUTCOME MEASURES: Description of patients with OHCA in terms of demographics, treatment and short-term outcome. RESULTS: A total of 929 patients with OHCA received an EMS response in the Cape Town metropole, corresponding to an annual prevalence of 23.2 per 100 000 persons. Most patients were adult (n=885; 96.5%) and male (n=526; 56.6%) with a median (IQR) age of 63 (26) years. The majority of cardiac arrests occurred in private residences (n=740; 79.7%) and presented with asystole (n=322; 34.6%). EMS resuscitation was only attempted in 7.4% (n=69) of cases and return of spontaneous circulation (ROSC) occurred in 1.3% (n=13) of cases. Almost all patients (n=909; 97.8%) were declared dead on the scene. CONCLUSION: To our knowledge, this was the largest study investigating OHCA ever undertaken in Africa. We found that while the incidence of OHCA in Cape Town was similar to the literature, resuscitation is attempted in very few patients and ROSC-rates are negligible. This may be as a consequence of protracted response times, poor patient prognosis or an underdeveloped and under-resourced Chain of Survival in low- to middle-income countries, like South Africa. The development of contextual guidelines given resources and disease burden is essential.

Waveform capnography in a South African prehospital service: Knowledge assessment of paramedics.

BACKGROUND: Waveform capnography has proven to be of great value in the provision of safe patient care especially in the intubated patient. Although seldom available, or used in African contexts, capnography has become standard practice in well-resourced out-of-hospital services for confirmation of intubation, and optimization of resuscitation and ventilation. To date there has been little research into the knowledge of out-of-hospital staff, both local and internationally, utilising capnography. This study describes the knowledge of paramedics who use waveform capnography in the out-of-hospital environment. METHODS: A cohort of advanced life support qualified paramedics in a private ambulance service in South Africa undertook a web-based survey around their background, training and use of capnography. Participants' knowledge was assessed by exploring their interpretation of waveform capnography and establishing attitudes pertaining to training and constraints of availability of capnography. RESULTS: Seventy eight paramedics responded, and most (91%) indicated they were likely to use capnography when the tool was available. The majority of training in capnography had been during their primary qualification (85%). Most participants indicated that they would like further training (91%). Use of capnography for confirmation of endotracheal tube placement and quality of compressions during cardiopulmonary resuscitation was well understood (correct in 94% and 84% respectively), while more complicated knowledge such as waveform changes during ventilation (66%) and the effect of hypovolaemia (48%) on capnography were lacking. CONCLUSION: Paramedics report using waveform capnography extensively when it is available in the South African out-of-hospital environment. Although the knowledge around capnography and its usage was found to be good in most areas, more complicated scenarios exposed flaws in the knowledge of many paramedics and suggest the need for improved and ongoing training, as well as incorporation into curricula as the field develops across the continent.

Waveform capnography in a South African prehospital service: Knowledge assessment of paramedics

Background:Waveform capnography has proven to be of great value in the provision of safe patient care especially in the intubated patient. Although seldom available, or used in African contexts, capnography has become standard practice in well-resourced out-of-hospital services for confirmation of intubation, and optimization of resuscitation and ventilation. To date there has been little research into the knowledge of out-of-hospital staff, both local and internationally, utilising capnography. This study describes the knowledge of paramedics who use waveform capnography in the out-of-hospital environment.Methods: A cohort of advanced life support qualified paramedics in a private ambulance service in South Africa undertook a web-based survey around their background, training and use of capnography. Participants' knowledge was assessed by exploring their interpretation of waveform capnography and establishing attitudes pertaining to training and constraints of availability of capnography. Results:Seventy eight paramedics responded, and most (91%) indicated they were likely to use capnography when the tool was available. The majority of training in capnography had been during their primary qualification (85%). Most participants indicated that they would like further training (91%). Use of capnography for confirmation of endotracheal tube placement and quality of compressions during cardiopulmonary resuscitation was well understood (correct in 94% and 84% respectively), while more complicated knowledge such as waveform changes during ventilation (66%) and the effect of hypovolaemia (48%) on capnography were lacking. Conclusion Paramedics report using waveform capnography extensively when it is available in the South African out-of-hospital environment. Although the knowledge around capnography and its usage was found to be good in most areas, more complicated scenarios exposed flaws in the knowledge of many paramedics and suggest the need for improved and ongoing training, as well as incorporation into curricula as the field develops across the continent

A descriptive analysis of endotracheal intubation in a South African Helicopter Emergency Medical Service.

INTRODUCTION: Helicopter Emergency Medical Services (HEMS) exists to supplement the operations of ground-based emergency care providers, mainly in high acuity cases. One of the important procedures frequently carried out by HEMS personnel is endotracheal intubation. Several HEMS providers exist in South Africa, with a mix of advanced life support personnel, however intubation success rates and adverse events have not been described in any local HEMS operation. METHODS: This was a retrospective chart review of intubation-related data collected by a HEMS operation based in Johannesburg over a 16-month period. First-pass and overall success rates were described, in addition to perceived airway difficulty, adverse events and other data. RESULTS: Of the 49 cases recorded in the study period, one was excluded leaving 48 cases for analysis. Most cases (n = 34, 71%) involved young male trauma patients who were intubated with rapid sequence intubation. The first pass success rate was 79% (n = 38) with an overall success rate of 98% (n = 47). At least one factor suggesting airway difficulty was present in 29% (n = 14) of cases, with most perceived airway difficulty related to the high prevalence of trauma cases. At least one adverse event occurred in 27% (n = 13) of cases with hypoxaemia, hypotension and bradycardia most prevalent. DISCUSSION: In this small sample of South African HEMS intubation cases, we found overall and first-pass success rates comparable to those reported in similar contexts.