My presentation on delegating lifesaving skills to non doctors. 13 September 2011, Soria Moria, Oslo Conference title: The 6th Conference on Global Health and Vaccination Research and the Norwegian Medical Association`s 125th Anniversary Conference: Contributions to Global Health Research, Capacity Building and Governance.

1. The VillageUniversity- save lives, save limbs Ole-Kristian Losvik – losvik@gmail.com Tromsoe Mine Victim Resource Center Soria Moria 13.Sept 2011 Tromsø model. Photo: TMC. Kongsberg model. Photo: US Navy

2. Epidemic of Trauma Every year 120 million persons are injured in low- and middle-income countries as compared to 11 million casualties in the high-income countries A worldwide epidemic of trauma is on. Injury is now the 4th leading cause of global deaths. WHO estimates a further 40% increase in global deaths from injury up to year 2030 Tromsø Mine Victim ResourceCenter works mainly with supportfor war victims

3. Save lives, save limbs 40% of land mine victims will die before reaching a hospital unless somebody is there to provide life support on the way (pre-intervention survey) In cooperation with local health authorities we trained paramedics in Iraq and Cambodia to take care of land mine victims. Part of the paramedic training was teaching village first helpers.

5. The training

6. Interventions

7. Can simple measures save their lives?

8. The villageuniversity Delegatinglifesaving skills to non-doctors Temporaryuniversity campus Students areselecetedlocally and should be trusted and wellknown in theircommunity Practicaland sometheory, butnoacademicacrobatics Research (to be continued…) Village First Helper training Vietnam (2007) Ref: Husum H, Gilbert M, Wisborg T. Training pre-hospital trauma care in low-income countries: the 'Village University' experience. Med Teach 2003;25(2):142-148.

9. Teaching Manual

10. Injury Charts The learning and training are also supported by the injury chart. Injury charts serves as a checklist for examination and also for treatment. The paramedics report that injury chart is useful for evaluating their own job. It is also used by local supervisors to ensure high quality of care.

11. Time to first medicalhelp Mortality (data from North Iraq 1997-2004)

12. Paramedic retention In North Iraq: Out of 88 paramedics certified in the years 1996-2004, 63 of them was still present in program in November 2005. Osman Hama Salah has trained several hundred first helpers during years as a paramedic

13. Takehomemessage After implementation of a low cost rural rescue system, there was a significant reduction in trauma mortality from 26.2% in 1997 to 11.8% in 2001. The mortality was stable after that. This shows that low-cost prehospital trauma systems improve survival in land mine victims where prehospital transit times are high. After trauma care training at rural makeshift training centers, non-graduate health workers can build efficient and sustainable rural rescue system

14. Ketamine pain relief Opioid analgesics is the “standard” for prehospital pain relief, however with some potential fatal side effects like respiratory depression, hypotension and loss of protective airway reflexes. In North Iraq paramedics have been using ketamine analgesia for 10 years. Aim: compare the effect of ketamine and opioids on physiologic severity indicators through retrospective study in Iraq, and prospective study in Vietnam.

15. Method (Iraq study) Retrospective interventional study in a trauma registry with parallel group design: no analgesia (n=275), opioid analgesia (n= 888), and ketamine analgesia (n=713). Physiologic severity score was calculated based on rated values for respiratory rate, blood pressure, and consciousness. Explanatory variable were analyzed in generalized linear model.

16. Preliminary analysis (Iraq study) Paramedic administration of analgesia is associated with positive change in physiologic severity score outcome (p=0.01) in a low-resource prehospital trauma system. The two groups receiving analgesia has a significant better positive change for respiration (p=0.0001) and blood pressure (p<0.0001). Ketamine analgesia is significantly better than opioid analgesia (p=0.0002) for blood pressure in patients with Injury Severity Score more than 8.

18. Further reading… Fosse E, Husum H: Surgery in Afghanistan: a light model for field surgery during war. Injury 1992; 23: 401 – 404. Husum H. Effects of early prehospital life support to war injured: the battle of Jalalabad, Afghanistan. PrehospDisast Med 1999; 14: 75 – 80. Husum H, Gilbert M, Wisborg T. Training prehospital trauma care in low-income countries: the “Village University” experience. Med Teach 2003; 25: 142 – 48. Husum H, Strada G. Measuring injury severity. The ISS as good as the NISS for penetrating injuries. PrehospDisast Med 2002; 17: 27 – 32. Husum H, Gilbert M, Wisborg T, Heng YV, Murad M. Rural prehospital trauma systems improve trauma outcome in low-income countries: a prospective study from North Iraq and Cambodia. J Trauma 2003; 55: 466 – 70. Husum H, Gilbert M, Wisborg T, Heng YV, Murad M. Landmine injuries: a study of 708 victims in North Iraq and Cambodia. Mil Med 2003; 168: 934 – 39. Husum H, Olsen T, Murad M, Heng YV, Wisborg T, Gilbert M. Preventing postinjury hypothermia during long prehospital evacuation. PrehospDisast Med 2002; 17: 23 – 26. Husum H, Gilbert Mlocalknow-how”. The Cartagena Summit on a Mine-free world, Colombia, December 2009. Murad MK, Larsen S, Husum H. What makes a survivor? Ten year ́s of experience with a trauma system in Iraq. WHO Bulletin 2011 (submitted). , Wisborg T, Heng YV, Murad M. Respiratory rate as prehospital triage tool in rural trauma. J Trauma 2003; 55: 466 – 70. Husum H, Resell K, Vorren G, Heng YV, Murad M, Gilbert M, Wisborg T. Chronic pain in landmine accident survivors in Cambodia and Kurdistan. SocSci Med 2002; 55:1813 – 16. Husum H, Heger T, Sundet M. Postinjury malaria: a study of trauma victims in Cambodia. J Trauma 2002; 52: 259 – 66. Sundet M, Heger T, Husum H. Postinjury malaria: a risk factor for wound infection and protracted recovery. Trop Med Int Health 2003; 9: 238 – 42. Heger T, Sundet M, Heng YV, Rattana Y, Husum H. Postinjury malaria: experiences of doctors in Battambang Province, Cambodia. SEAsian J Trop Med 2005; 36: 811 – 15. Hedelin H, Husum H, Mudhafar M, Edvardsen O. Traumavårdifattigaländer - en byskollektivaangelägenhet. Omhändertagandetavminskadade på landsbygdeninorraIrak [summary] . SvLäktid 2006; 7: 460 – 63. Edvardsen, O. Et nettverkavførstehjelpereidetminelagte Nord-Irak: et spørsmålom liv ellerdød. Thesis, Master Health Science. Tromso University, 2006. Chandy H, Steinholt M, Husum H. Delivery Life Support: chain-of-survival for complicated deliveries in rural Cambodia, a preliminary report. NursHlthSci 2007; 9; 263 – 269.

19. ChandyH, Ol HS, Heng YV, Husum H. Comparing two survey methods for maternal and neonatal mortality in rural Cambodia. Women Birth 2008; 21: 9-12 Tajsic N, Husum H. Reconstructive microsurgery can be done in low-resource settings: experiences from a wartime scenario. J Trauma. 2008; 65:1463-7. Heng YV, Davoung C, Husum H. Trauma surgery at the District Hospital: a controlled study of trauma training for rural non-graduate surgeons in Cambodia. PrehospDisast Med 2008; 23: 483 – 90 Wisborg T, Murad M, Edvardsen O, Husum H. Trauma systems in Iraq 1997-2004: adaptation and maturation. J Trauma 2008; 64: 1342 – 48 Tajsic N, Winkel R, Hoffmann R, Husum H. Sural perforator flap for reconstructive surgery in the lower leg and the foot: a clinical study of 86 patients with post-traumatic osteomyelitis. J PlastReconstrAesthetSurg 2009: 62: 1701 – 8 Husum H, Edvardsen. Trauma as Poverty. Methodological problems when reality gets nasty. In: Ingstad B, Eide H. Disability and Poverty (London 2009, in press). Ol HS, Bjoerkvoll B, Sothy S, Heng YV, Hoel H, Husebekk A, Gutteberg T, Larsen S, Husum H. Prevalence of Hepatitis B and Hepatitis C virus infection in potential blood donors in rural Cambodia. Se Asian J Trop Med 2009; 40: 963 – 71 Heger T, Han SC, Sundet M, Larsen S, Husum H. Early diagnosis and treatment of malaria Falciparum in Cambodian trauma patients. SE Asian J Trop Med 2009; 40: 1135 – 47 Husum H. Severity scoring in rural trauma. Rural Remote Hlth 9 (online) 2009: 1226 Tajsi! N, Winkel R, Schlageter M, Hoffmann R, Husum H. Saphenous perforator flap for reconstructive surgery in the lower leg and the foot; a clinical study of 50 patients with post- traumatic osteomyelitis. J Trauma 2010; 68: 1200 – 7 Husum H. Rural trauma in Iran: are the data reliable? Rural Remote Hlth 10 (online) 2010: 1387 Heng YV, Husum H, Murad MK, Wisborg T. Improving rural prehospital care in the absence of formal emergency medical services. In: Mock C, Julliard C, Joshipura M, Goosen J (Eds). Strengthening care for the injured: Success stories and lessons learned from around the world. World Health Organization, Geneva 2010: 3 – 7 Murad M, Husum H. Trained lay first-helpers reduce trauma mortality: a controlled study of rural trauma in Iraq. J PrehospDisast Med 2010; 25:533 – 39 Bjoerkvoll B, Viet L, Ol S, Lan TN, Sothy S, Hoel H, Husebekk A, Gutteberg T, Larsen S, Husum H.: Screening test accuracy among potential blood donors. Poor rapid test result accuracy in screening of potential blood donors of HbsAg, anti-HBc and anti-HCV to detect hepatitis B and c virus infection in rural Cambodia and Vietnam: Southeast Asian Journal of Trop Med Public Health, volume 41, September 2010. Viet L, Lan TN, Ty PX, Hoel H, Husebekk A, Gutteberg T, Larsen S, Husum H. Prevalence of hepatitis B and hepatitis C virus infections in potential blood donors in rural Vietnam. Ind J Med Res 2010 (submitted) Lejon, H, Edvardsen, O, Husum, H: A qualitative study of first level care providers in rural Cambodia: Are Traditional Birth Attendants skilled or non-skilled care providers? University of North Norway, Tromsoe Husum, Hans: “Immediate temporary prosthesis, local material and

20. Thanks… twitter.com/losol losvik@gmail.com Thanks to NorwegianMinistry of Foreign Affairs for supportthrough 15 years! MFA

21. Current research Trauma care as mass mobilization What makes a survivor? Qualitative and quantitative studies inside the minefields to explore trauma care – not only as medical interventions – but as a structured social response by the affected communities. Self-help groups for long-term post-injury rehabilitation. Delegating life saving skills to staff in District Hospitals TMC explores the capacity of the local Rural District Hospital, running training programs that delegate life-saving surgical skill to local medical assistants. Early Temporary Walking Aid Most disabled survivors in the South suffer from incapacitating pain syndromes. Can Early Temporary Walking Aid made of local materials by local technicians prevent chronic pain and promote function?

22. Current research (2) Post-injury malaria – the Poor Man’s burden Post-injury malaria is a common complication to primary surgery in malaria endemic areas. Post-injury malaria is a risk factor for wound infection and protracts recovery. We are now exploring measures to prevent the complication, affecting millions living in equatorial areas. Delivery Life Support The death tolls of mothers and newborn in the rural South exceed by far the numbers being killed by land mines and accidents. TMC upgrades the trauma systems in Cambodia and Afghanistan to also manage deliveries. Rural Blood Banking Trauma patients and bleeding mothers need blood! We are now exploring local solutions for safe blood transfusion in areas where HIV, hepatitis, and malaria is endemic.

23. Current research (3) Pain relief Does proper pre-hospital analgesia improve trauma-outcome by improved breathing and circulation in the victim? What is the best drug for pain-relief during the strenuous evacuation to the hospital? Retrospective data analysis and prospective clinical trials ongoing in Cambodia and Vietnam Documentation and systematic data collection Proper documentation in all stages of the chain of survival through ten years provides valuable data for comprehensive research. It is a gold-mine for retrospective and comparative studies to improve understanding of factors promoting survival and better outcome for poor trauma victims. New ways of evaluating impact are explored through film and video documentation.

24. Film Instruksjonsvideoen Save Lives, Save Limbs Demonstrasjonsvideoer (eks rehab workshop) Dokumentaren ”Å leve i et minefelt” av Marit Gjertsen Neste (?): Krigen – offeret, soldaten, familien, medicen

25. Beyond survival...?

26. Courses in medical research The theory of science. Research ethics. Study design. Research protocols. Controlled clinical trials. Basic biostatistics. Trauma Registry analysis. Quantitative studies: Scientific writing. Qualitative methods: Data gathering. Qualitative methods: Analysis. Scientific writing

27. Illustrations by Hans Husum

28. Principles Confidence: We all learn better when feeling confident and at home. Troubleshooting: Identify the problem, and solve it. Learning by doing: Lectures constitute not more than 25% of the course, and practice should always follow classroom sessions. Local control: After three years, the students should have the capacity to perform as local instructors. (7)

29. About ”Save Lives, Save Limbs” “Save Lives, Save Limbs” is a manual in basic and advanced trauma care for health workers in countries affected my the mine epidemic and the epidemic of injuries in general. Lots of clear drawings help the reader understand procedures, and a large numer of photographs of real injuries from the fields makes it practical and useful for health workers, medical and nursing students, medical doctors and lay people. "The Village University" teaching model is described in detail.