A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / The rate of technology expansion is rapidly covering even the most remote parts of the globe and in the lowest resource settings. With globalization however, low and middle income areas are facing emerging health issues such as injuries and chronic medical conditions. With these illnesses, there are inevitable demands on emergency services. It has been thought that technology be utilized to augment emergency medical care in such settings where formal Emergency Medical Services. To aggregate and analyze the existing literature on the topic a systematic literature review was conducted. This study analyzed the existing literature on prehospital emergency care in settings in which no formal EMS services were utilized. Four databases were searched with inclusion and exclusion criteria, yielding 1782 results. The initial screening excluded all but 21 articles. Of the 21 articles in full review, 15 were included in the final review. Studies included in the final review were grouped into those reporting outcomes from five categories: Feasibility, Quality of Care, Response Time, Patient Outcomes, and Cost Effectiveness. Only one study was identified to be of high quality. There was a lack of studies with adequate statistical analysis to conduct statistical aggregation. Most studies however reported prehospital telemedicine in settings without EMS to be feasible, provide quality care, are be cost effective. However, the lack of statistical analysis makes it difficult to make conclusions. Also, several studies did show response time of a trained basic life support volunteer to be faster than EMS in many of the settings. But no positive health outcomes were observed in patients treated with projects utilizing technology in the prehospital setting. The prehospital emergency medicine setting is a young field of study that may have significant hurdles in application. The studies conducted have shown promise in the use of technology in prehospital settings without formal EMS services, but are not robust enough to make strong conclusions or recommendations that could be put into practice. Thus, more robust, statistically oriented research is imperative in the field so that we can fully explore the potential of technology in the prehospital setting, especially in low resource and rural settings without formal EMS services. With more robust studies, we can hope to integrate new technologies into practice and better serve the populations without adequate EMS coverage to provide more timely emergency care.

Abstract Trauma patients are a significant patient group for emergency medical services (EMS). Not only are injuries a significant cause of death, they also have a significant long-term impact on functionality and quality of life. Previous studies have shown that the injury-related mortality rate is higher in sparsely populated areas and that the majority of patients die before the arrival of EMS. Intensive care mortality is significant, and half of seriously injured patients develop multiple organ dysfunction. Airway management is one of the most important procedures that EMS provide for a critically injured patient, but making high-quality care available in a sparsely populated area is challenging. Seriously injured patients also appear to benefit from being transported directly to a trauma centre. In recent years particular attention has been given to the level and availability of EMS. Hospitals’ readiness to provide acute surgery is also being reorganised. More information is needed about the frequency, circumstances, outcome and acute care of serious and fatal injuries so that health care resources can be allotted appropriately and requirements for prevention can be identified. The purpose of this research was to investigate the frequency and circumstances of injury-related deaths in Northern Finland and the prognosis of trauma patients encountered by the Finnish helicopter emergency services (FinnHEMS). A particular objective was to examine differences between rural and urban areas. The National Advisory Committee for Aeronautics (NACA) severity score’s ability to predict 30-day mortality was also examined. The fourth part of the study aimed to investigate the pre-hospital airway management performed by non-physicians in Northern Finland. The study material was comprised of trauma deaths that occurred in Northern Finland in 2007–2011, trauma patients encountered by FinnHEMS units in Northern Finland in 2012–2013, patients encountered by HEMS in Northern Norway in 1999–2009 and a questionnaire regarding pre-hospital airway management to non-physicians. The study concluded that the rate of trauma deaths is high in Northern Finland, and the influence of alcohol was found in nearly half of pre-hospital trauma death cases. A larger portion of pre-hospital deaths also took place in rural areas. Trauma patients encountered by FinnHEMS units in urban areas who survived to hospital, appeared to have higher 30-day mortality than patients injured in rural areas. The most probable explanation for this difference is that patients injured in urban areas survive to hospital, while trauma patients in rural areas die pre-hospital. The NACA score was found to reliably predict 30-day mortality. Due to its simplicity, the NACA score can be used to compare patient material from different HEMS bases. It was found that non-physicians seldom performed airway management. On average, the frequency of performing airway management was low, and there is a need to improve maintenance of skills. / Tiivistelmä Vammapotilaat ovat merkittävä ensi- ja tehohoidon potilasryhmä. Paisi, että vammautumiset ovat merkittävä kuolinsyy, aiheuttavat ne myös merkittäviä pitkäaikaisvaikutuksia toimintakykyyn ja elämänlaatuun. Aikaisemmissa tutkimuksissa on osoitettu, että vammakuolleisuus on yleisempää harvaanasutuilla seuduilla ja valtaosa potilaista kuolee jo ennen ensihoidon saapumista paikalle. Tehohoitokuolleisuus on merkittävää ja puolet vaikeasti loukkaantuneista potilaista kärsii monielinvauriosta. Ensihoidon tärkeimpiä tehtäviä kriittisesti vammautuneilla on hengitystien varmistaminen, mutta korkeatasoisen hoidon saatavuus harvaanasutulla seudulla on haasteellista. Vaikeasti vammautuneet potilaat näyttävät myös hyötyvän kuljetuksesta suoraan lopulliseen hoitopaikkaan. Viime vuosina ensihoidon tasoon ja saatavuuteen on kiinnitetty erityistä huomiota. Lisäksi sairaaloiden päivystysvalmiuden uudelleenorganisointi on käynnissä. Lisätietoa tarvitaan vakavien ja kuolemaan johtavien vammojen esiintyvyydestä ja olosuhteista, ennusteesta sekä akuuttihoidon toteutumisesta, jotta terveydenhuollon resursseja voitaisiin kohdentaa tarkoituksenmukaisesti ja ennaltaehkäisyn tarpeet voitaisiin tunnistaa. Tämän tutkimuksen tarkoituksena oli selvittää vammakuolemien esiintyvyyttä ja olosuhteita Pohjois-Suomessa sekä suomalaisten lääkintä- ja lääkärihelikopteriyksikköjen (FinnHEMS) kohtaamien vammapotilaiden ennustetta. Erityisenä tavoitteena oli tutkia maaseutu- ja kaupunkialueiden eroja. Lisäksi tutkittiin National Advisory Committee for Aeronautics (NACA)- vaikeusasteluokittelun kykyä ennustaa 30 päivän kuolleisuutta. Neljännen osatyön tavoitteena oli tutkia ensihoitajien suorittaman hengitystien varmistamisen käytäntöä Pohjois-Suomessa. Tutkimusaineisto koostui vuosina 2007‒2011 Pohjois-Suomessa tapahtuneista vammakuolemista, FinnHEMS:in yksiköiden kohtaamista vammapotilaista Pohjois-Suomessa vuosina 2012‒2013, Pohjois-Norjan pelastushelikopterin kohtaamista potilaista vuosina 1999‒2009 sekä ensihoitajille tehdystä kyselytutkimuksesta hengitystien hallintaan liittyen. Tutkimuksessa todettiin, että kuolemaan johtaneiden vammojen esiintyvyys on korkea Pohjois-Suomessa. Lisäksi havaittiin, että lähes puoleen sairaalan ulkopuolella tapahtuneisiin vammapotilaiden kuolintapauksiin liittyi alkoholi. Maaseudulla myös suurempi osa menehtyi sairaalan ulkopuolella. FinnHEMS:in yksiköiden kaupunkialueella kohtaamilla vammapotilailla, jotka selvisivät sairaalaan, havaittiin viitettä korkeampaan 30 päivän kuolleisuuteen verrattuna maaseudulla vammautuneihin. Ero johtuu todennäköisemmin siitä, että kaupunkialueella vammautuneet ehtivät sairaalaan kun taas maaseudulla vammapotilaat kuolevat jo ennen ensihoitopalvelun saapumista. NACA-vaikeusasteluokittelun todettiin ennustavan luotettavasti 30 päivän kuolleisuutta. Yksinkertaisuutensa vuoksi se soveltuu potilasmateriaalin vertailemiseen eri tukikohtien välillä. Ensihoitajan suorittama hengitystien varmistaminen havaittiin olevan harvinaista. Keskimääräisesti suoritteita tapahtui harvoin, ja taitojen ylläpitämisessä oli parantamisen varaa.