Objectives: 1. To describe variations in major trauma between rural and urban residents of Ontario in terms of external causes, severities, prehospital care and clinical outcomes. 2. To determine whether prehospital intubation improves survival to hospital discharge among victims of major trauma. Methods: The study involved secondary analyses of data from the Ontario Prehospital Advanced Life Support Study (OPALS). OPALS is the largest study of prehospital emergency medical services conducted worldwide. 1. Rural-urban status of trauma patients was determined using modified Beale Codes. Differences in trauma characteristics and patient care were compared among four geographic groups (Large Metro, Medium Metro, Small Metro, Rural). 2. Patients who were intubated in the field were individually matched with non-intubated patients by patient age, injury severity score category, abbreviated head injury score category, and exact Glasgow coma scores. Cox regression was used to estimate the effect of prehospital intubation on patients' survival to hospital discharge, stratifying on patient matching. Results: 1. Patients in the large metro and rural groups had higher injury severity scores (medial 25, 24, respectively) than the other two groups (median=22). Paramedics generally spent more time in rural and large metro areas (median=37.4, 36.6 minutes respectively) than in medium and small metro (median=32.0, 30.7 minutes respectively) areas. Response times and transport times in rural groups were significantly longer than the other three groups, while scene times in the large metro group were significantly longer compared with the other geographic groups. There were no significant differences in survival rates by geographic group. 2. There were no significantly differences between the intubated and the non-intubated groups by age, sex, Glasgow coma scores, injury severity score, and systolic blood pressure category. Prehospital intubated patients exprienced a 3-fold risk of mortality after adjustment for potential confounders (HR2.9; 95% CI 1.4 to 5.8). Conclusions: 1. While response and transport times for major trauma were longer in rural areas, there were no significant differences in mortality in patients with different rural urban status. 2. Prehosptial intubation showed a negative association with survival among major trauma patients. Further randomized trials are required to invesitigate this clinical issue. / Thesis (Master, Community Health & Epidemiology) -- Queen's University, 2007-10-24 11:58:53.955

Introduction: Trauma is one of the leading causes of premature death and disability in South Africa. There is a paucity of data describing the prehospital trauma burden in sub-Saharan Africa. The aim of this study was to describe the epidemiology and common trauma emergencies managed by the Western Cape Government emergency medical service (WCG EMS) in South Africa. Methods: The WCG EMS call centre registry was retrospectively analysed for all trauma patients managed between 01 July 2017 to 30 June 2018. A descriptive analysis of the data was performed using standard procedures for all variables. To date, this was the first analysis of this dataset or any prehospital trauma burden managed in the Western Cape of South Africa. Results: The WCG EMS managed 492 303 cases during the study period. Of these cases, 168 980 (34.3%) or 25.9 per 1000 population were trauma related. However, only 91 196 met the inclusion criteria for the study. The majority of patients (66.4%) were males and between the socio-economically active ages of 21-40 years old (54.0%). Assaults were the most common cause of trauma emergencies, accounting for 50.2% of the EMS case load managed. The patient acuity was categorised as being urgent for 47.5% of the cases, and 74.9% of the prehospital trauma burden was transported to a secondary level health care facility for definitive care. Conclusion: This is the first report of the prehospital trauma burden managed in the Western Cape of South Africa. The Western Cape suffers a unique trauma burden that differs from what is described by the WHO or any other LMIC. It also provides the foundation for further research towards understanding the emergency care needs in South Africa and to support Afrocentric health care solutions to decrease this public health crisis.

Background: Protection against cold is vitally important in prehospital trauma care to reduce heat loss and prevent body core cooling. Objectives: Evaluate the effect on cold stress and thermoregulation in volunteer subjects byutilising additional insulation on a spineboard (I). Determine thermal insulation properties of blankets and rescue bags in different wind conditions (II). Establish the utility of wet clothing removal or the addition of a vapour barrier by determining the effect on heat loss within different levels of insulation in cold and warm ambient temperatures (III) and evaluating the effect on cold stress and thermoregulation in volunteer subjects (IV). Methods: Aural canal temperature, sensation of shivering and cold discomfort was evaluated in volunteer subjects, immobilised on non-insulated (n=10) or insulated (n=9) spineboards in cold outdoor conditions (I). A thermal manikin was setup inside a climatic chamber and total resultant thermal insulation for the selected ensembles was determined in low, moderate and high wind conditions (II). Dry and wet heat loss and the effect of wet clothing removal or the addition of a vapour barrier was determined with the thermal manikin dressed in either dry, wet or no clothing; with or without a vapour barrier; and with three different levels of insulation in warm and cold ambient conditions (III). The effect on metabolic rate, oesophageal temperature, skin temperature, body heat storage, heart rate, and cold discomfort by wet clothing removal or the addition of a vapour barrier was evaluated in volunteer subjects (n=8), wearing wet clothing in a cold climatic chamber during four different insulation protocols in a cross-over design (IV). Results: Additional insulation on a spine board rendered a significant reduction of estimated shivering but there was no significant difference in aural canal temperature or cold discomfort (I). In low wind conditions, thermal insulation correlated to thickness of the insulation ensemble. In greater air velocities, thermal insulation was better preserved for ensembles that were windproof and resistant to the compressive effect of the wind (II). Wet clothing removal or the use of a vapour barrier reduced total heat loss by about one fourth in the cold environment and about one third in the warm environment (III). In cold stressed wet subjects, with limited insulation applied, wet clothing removal or the addition of a vapour barrier significantly reduced metabolic rate, increased skin rewarming rate, and improved total body heat storage but there was no significant difference in heart rate or oesophageal temperature cooling rate (IV). Similar effects on heat loss and cold stress was also achieved by increasing the insulation. Cold discomfort was significantly reduced with the addition of a vapour barrier and with an increased insulation but not with wet clothing removal. Conclusions: Additional insulation on a spine board might aid in reducing cold stress inprolonged transportations in a cold environment. In extended on scene durations, the use of a windproof and compression resistant outer cover is crucial to maintain adequate thermal insulation. In a sustained cold environment in which sufficient insulation is not available, wet clothing removal or the use of a vapour barrier might be considerably important reducing heat loss and relieving cold stress.

Prehospital emergency care systems are complex and do not necessarily respond predictably to changes in management. A combined discrete-continuous simulation model focusing on trauma care was designed and implemented in SIMSCRIPT II.5 to allow prediction of the systems response to policy changes in terms of its effect on the system and on patient survival. The utility of the completed model was demonstrated by the results of experiments on triage and helicopter dispatching policies. Experiments on current and two alternate triage policies showed that helicopter utilization is significantly increased by more liberal triage to Level 1 trauma centers, which was expected, but that the waiting time for pending accidents tended to decrease, an unexpected consequence. Experiments on helicopter dispatch policy showed that liberalization of the dispatch policy would have much greater consequences than would changing the triage criteria. Again, this result was unexpected and has received little attention from system planners and administrators, especially with respect to the degree of discussion and controversy surrounding triage criteria.