The Current Situation: Trauma Care in Rural Bolivia
A few weeks ago, I met a patient whose car slid off a cliff in the rural Yungas Jungles. Local villagers rescued him and his wife, and he was fortunate to survive with only a broken femur. However, upon arrival to the nearest health center, he discovered that the local physician did not have any training in splinting fractures. After working with the physician to immobilize his leg, he was packed into the back of an ambulance (a generic 4×4 without a backseat and only blankets for padding) and transferred 14 hours to La Paz by the local villagers. While the final result may have been quite different had the injury been more severe, this story provides a very insightful look at current trauma systems in resource-limited settings.
The Rationale for Step-Wise Trauma Development
In 2000, the WHO convened a meeting of international experts to discuss how to strengthen prehospital care around the world, particularly in low and middle-income countries (LMICs). This group eventually published the WHO’s 2005 “Prehospital Trauma Care Systems” report, which recognizes 3 general phases of prehospital trauma care development:
- First Responder Care. Where no prehospital trauma care system exists, the first and most basic tier of a system can be established by teaching interested community members basic first aid techniques. With this level of training, a kit of basic supplies, and access to a suitable vehicle, these individuals can provide an acceptable level of trauma care while transporting an injured person to an appropriate healthcare facility.
- Basic Prehospital Trauma Care. The second tier of care can be provided at the community level by individuals with advanced training in prehospital trauma care, including scene management, extrication and rescue, stabilization, immobilization, and the transport of injured patients. Many paid ambulance personnel around the world are trained to this standard.
- Advanced Prehospital Trauma Care. This third tier of care involves the maintenance of a fleet of sophisticated ground/air ambulances, provision of advanced invasive techniques by professional prehospital care providers, and the establishment of complex regional call (9-1-1) centers with highly integrated wireless communications networks. This is the level of prehospital care we know and depend on in the US.
And so, if you had to choose one system to implement, Advanced Prehospital Trauma Care seems to be the obvious choice, right? Interestingly enough, despite the high costs of advanced life support interventions in this third tier of care, there is little evidence that these interventions benefit more than a small subset of the most critically ill or injured victims. This is particularly true in situations in which basic care is quickly and consistently applied. In fact, most of the benefits of prehospital trauma care can be readily realized if vital interventions of the first and second tier are applied in a timely manner.
Many lives can be saved and disabilities prevented by teaching motivated people how to respond at the scene of an accident. Consequently, this is exactly what we are doing here in Bolivia: we have developed an intensive Trauma First Responders Course to equip local volunteers with the necessary knowledge/skills of trauma management. Through interactive lectures and practical sessions, we cover the important topics required to provide First Responder Care and Basic Prehospital Trauma Care as described in tiers 1 and 2 above. By creating a systematic method for training both rural community members and medical professionals, we are beginning to establish a basic trauma care system throughout rural Bolivia that will provide a foundation for developing a more advanced trauma care network in the future.