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Prehospital and Emergency Care

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  • 245
    Prehospital and Emergency Care
    Amardeep Thind, Renee Hsia, Jackie Mabweijano,
    Eduardo Romero Hicks, Ahmed Zakariah, and Charles N. Mock
    Chapter
    14
    INTRODUCTION
    Disease or illness can strike at any time. If the condition
    is acute, or if the injury is life-threatening or limb-
    threatening, immediate care is needed. These time-
    dependent conditions that affect both adults and children
    may be due to medical, surgical, or obstetric conditions.
    They may result from acute injuries or illnesses or from
    exacerbations of chronic disease.
    In low- and middle-income countries (LMICs),
    patients with such conditions may face delays of hours
    or even days before reaching the nearest medical facility
    or provider. Transportation may be provided by ambu-
    lance, but more often it is provided by laypersons using
    the handiest mode of transport available (Arellano,
    Mello, and Clark 2010; Khorasani-Zavareh and others
    2009; Nguyen and others 2008; Ramanujam and
    Aschkenasy 2007). Health care before arrival at heath
    facilities may be provided by trained paramedics or by
    laypersons; quite often, however, no health care is pro-
    vided (Bavonratanavech 2003; Khorasani-Zavareh and
    others 2009; Nguyen and others 2008; Solagberu and
    others 2009).
    In contrast to systems in high-income countries
    (HICs), the prehospital and emergency medical systems
    of LMICs are often rudimentary. Justifiably, health
    systems in LMICs have focused on increasing access
    to health care by building facility-based health care
    systems. Such thinking is abetted by a perception that
    the provision of prehospital and emergency care is not
    cost-effective in LMICs (Kobusingye and others 2005),
    leading to policies that allocate the bulk of scarce health
    care resources elsewhere.
    This chapter identifies the scale of the challenge by
    presenting data on the burden of disease that prehospital
    and emergency care systems in LMICs could potentially
    address. It then describes the common health care
    delivery structures in these countries and assesses the
    literature on costs and effectiveness of such mechanisms.
    It closes with a discussion of future directions in research
    and policy.
    BURDEN OF DISEASE
    The burden of disease that can potentially be addressed by
    prehospital and emergency care in LMICs ( figure 14.1)
    was derived from the diseases and disease conditions
    used by Kobusingye and others in their chapter on
    emergency medical services in Disease Control Priorities
    in Developing Countries, second edition (Jamison and
    others 2006). The latest data for these conditions
    were extracted from the World Health Organizations
    (WHO’s) Global Health Estimates (WHO 2013). Data
    for the diseases and conditions are clustered into three
    groups:
    Communicable and maternal conditions
    • Chronic conditions
    • Injuries
    Corresponding author: Amardeep Thind, MD, PhD, University of Western Ontario, athind2@uwo.ca
  • 246 Essential Surgery
    The communicable and maternal conditions group
    includes the following:
    Diarrheal diseases: cholera, other salmonella infec-
    tions, shigellosis, E. coli, campylobacter, amoebiasis,
    cryptosporidiosis, rotavirus, typhoid and paraty-
    phoid fevers
    Lower respiratory infections: influenza, pneumococ-
    cal pneumonia, haemophilus influenzae pneumonia,
    respiratory syncytial virus pneumonia, other lower
    respiratory infections
    Childhood conditions: diphtheria, whooping cough,
    tetanus, measles
    • Meningitis
    • Malaria
    Maternal conditions: hemorrhage, sepsis, hyperten-
    sive disorders of pregnancy, obstructed labor, and
    abortion
    The chronic conditions group includes the following:
    Ischemic heart disease
    • Cerebrovascular disease
    Hypertensive heart disease
    • Asthma
    • Diabetes
    The injuries group includes the following:
    Unintentional: transport and nontransport injuries,
    and forces of nature
    Intentional: self-harm, interpersonal violence, war,
    and legal intervention
    Our estimates suggest that out of the approximately
    45 million deaths in LMICs each year, 54 percent, or
    24.3 million, are due to conditions that are potentially
    addressable by prehospital and emergency care. This
    loss translates into a staggering 1,023 million DALYs, or
    932 million years of life lost (YLL) to premature mor-
    tality. From a morbidity perspective, this disease burden
    translates into 91.4 million years lived with disability
    (YLD). While ischemic heart disease and cerebrovas-
    cular disease contribute the largest number of deaths,
    unintentional injuries are the single largest contribu-
    tor to the DALYs. The largest contributors to YLL are
    unintentional injuries, lower respiratory infections, and
    ischemic heart disease.
    In this array of disease burden, maternal condi-
    tions (hemorrhage, sepsis, obstructed labor, and abor-
    tion) and injuries may require surgical intervention.
    Nearly 19 percent (or 4.7 million) of these 24.3 million
    deaths in LMICs are surgically treatable. This number
    Figure 14.1 Burden of Disease Potentially Addressable by Prehospital and Emergency Care in LMICs
    Source: Data from WHO 2013.
    Note: DALYs = disability-adjusted life years; LMICs = low- and middle-income countries; YLD = years lived with disability; YLL = years of life lost.
    0
    20
    40
    60
    80
    100
    120
    140
    160
    180
    200
    Communicable and maternal conditions
    Childhood conditions
    Meningitis
    Malaria
    Maternal conditions
    Hypertensive heart disease
    Asthma
    Diabetes
    Intentional
    Chronic conditions Injuries
    Millions
    Deaths DALYs YLL YLD
    Total addressable deaths = 24.3 million
    Total addressable DALYs lost = 1,023 million
    Total addressable YLL = 932 million
    Total addressable YLD = 91.4 million
    Diarrheal diseases
    Lower respiratory infections
    Ischemic heart disease
    Cerebrovascular disease
    Unintentional
  • Prehospital and Emergency Care 247
    corresponds to nearly 28 percent—285 million—of the
    DALYs, or 25 percent—286 million—of the YLL. From
    a morbidity perspective, surgically treatable conditions
    account for 38 million YLD, or 41 percent of the condi-
    tions that are potentially addressable by prehospital and
    emergency care.
    Figures 14.2–14.5 depict the regional variations in
    mortality, DALYs, YLL, and YLD. By virtue of their
    large populations, South Asia and East Asia and the
    Pacific account for 56 percent of the addressable deaths
    ( figure 14.2). South Asia and Sub-Saharan Africa
    account for 61 percent of the DALYs (figure 14.3), and
    Sub-Saharan Africa contributes 33 percent of the YLL
    (figure 14.4). Morbidity is the highest in East Asia and
    the Pacific, which accounts for 31 percent of the YLD
    (figure 14.5).
    CURRENT DELIVERY SYSTEMS
    To develop and enhance the capacity to provide effective
    emergency care, it is essential to view such care in the
    context of the overall health system rather than as a
    discrete and independent unit. Emergency care covers a
    range of services, from the care provided by laypersons at
    the scene to that provided in a dedicated trauma facility.
    Between these two phases lie the transportation systems,
    health centers, and first-level hospitals. Patient survival
    depends on how well each component functions.
    The organization and operation of the prehospital
    care system vary by country, but should be linked to
    the local hospitals or facilities to which patients are
    to be transported. When prehospital transportation
    is poor or absent, deaths occur that could have been
    prevented by inexpensive procedures (Mock and others
    1998). Most maternal deaths may fall into this category.
    Poor quality of care at hospitals will lead to in-hospital
    deaths and may eventually discourage communities that
    might have the capacity to promptly transfer patients
    to such facilities (Leigh and others 1997). Skilled and
    motivated personnel, appropriate supplies, pharma-
    ceuticals, equipment, coordination, and management
    oriented to the needs of the critically ill all contribute
    to making emergency care effective in reducing death
    and disability.
    Tiers of Care
    Tier One. Prehospital care encompasses the care pro-
    vided by the community—from the scene of injury,
    home, school, or other location—until the patient
    arrives at a formal health care facility. This care should
    comprise basic and proven strategies and the most
    appropriate personnel, equipment, and supplies needed
    to assess, prioritize, and institute interventions to min-
    imize the probability of death or disability. The most-
    effective strategies are basic and inexpensive; the lack of
    high-technology interventions should not deter efforts
    Figure 14.2 Regional Distribution of Deaths Addressable by Prehospital
    and Emergency Care in LMICs
    Percent
    Source: Data from WHO 2013.
    Note: LMICs = low- and middle-income countries.
    East Asia and
    the Pacific,
    29
    Europe and
    Central Asia,
    12
    Latin America and
    the Caribbean,
    7
    Middle East and
    North Africa,
    4
    Total addressable deaths in LMICs = 24.3 million
    South Asia,
    27
    Sub-Saharan
    Africa,
    21
    Figure 14.3 Regional Distribution of DALYs Potentially Addressable by
    Prehospital and Emergency Care in LMICs
    Percent
    Source: Data from the WHO Global Health Estimates (WHO 2013).
    Note: DALY = disability-adjusted life year; LMICs = low- and middle-income countries.
    East Asia and
    the Pacific,
    21
    Europe and
    Central Asia,
    8
    Latin America and
    the Caribbean,
    6
    Middle East and
    North Africa,
    4
    Total addressable DALYs in LMICs = 1,023 million
    South Asia,
    29
    Sub-Saharan
    Africa,
    32

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Mô tả tài liệu:

Prehospital and Emergency Care

Points out that life-threatening or limb-threatening conditions requiring immediate care face significant delays in reaching medical care in low- and middle-income countries (LMICs). Communicable and maternal conditions, chronic conditions, and injuries (both intentional and unintentional) cause 24.3 million deaths in LMICs and translate into a staggering 1,023 million DALYs (disability-adjusted life years). Prehospital care encompasses first responder care provided by the community—from the scene of injury, home, school, or other location—until the patient arrives at a formal health care facility – and paramedical care such as paid ambulance personnel or fire or police personnel. In most of East Asia and the Pacific, South Asia, and Sub-Saharan Africa, commercial ambulances may not be available, and transport options mean private motorized or nonmotorized vehicles. Training of community paramedics and first responders remains a challenge as illustrated by experiences in Iraq and Cambodia. The wide availability of cellular phones has revolutionized both the availability and the cost of communications for prehospital emergency care system.

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