Cost-effectiveness and benefit of alternatives to improve training for prehospital trauma care in Mexico. Effects of 2 patterns of prehospital care on the outcome of patients with severe head injury. The impact of advanced prehospital emergency care on the mortality of severely brain-injured patients.
In Latin America, there is a preponderance of prehospital trauma deaths. However, scarce resources mandate that any improvements in prehospital medical care must be cost-effective. This study sought to evaluate the cost-effectiveness of several approaches to improving training for personnel in three ambulance services in Mexico.
                In Monterrey, training was augmented with PreHospital Trauma Life Support (PHTLS) at a cost of [US] dollar 150 per medic trained. In San Pedro, training was augmented with Basic Trauma Life Support (BTLS), Advanced Cardiac Life Support (ACLS), and a locally designed airway management course, at a cost of dollar 400 per medic. Process and outcome of trauma care were assessed before and after the training of these medics and at a control site.
                The training was effective for both intervention services, with increases in basic airway maneuvers for patients in respiratory distress in Monterrey (16% before versus 39% after) and San Pedro (14% versus 64%). The role of endotrachal intubation for patients with respiratory distress increased only in San Pedro (5% versus 46%), in which the most intensive Advanced Life Support (ALS) training had been provided. However, mortality decreased only in Monterrey, where it had been the highest (8.2% before versus 4.7% after) and where the simplest and lowest cost interventions were implemented. There was no change in process or outcome in the control site.
                This study highlights the importance of assuring uniform, basic training for all prehospital providers. This is a more cost-effective approach than is higher-cost ALS training for improving prehospital trauma care in environments such as Latin America. A pattern of prehospital care combining advanced life support, physician staffing, and helicopter transport improves the outcome of patients with severe brain injuries, compared with combined expanded basic life support, nurse staffing, and ground transport.
                Inception cohort from the data set of a population-based, prospective study on major trauma.
                Prehospital and hospital trauma systems of an Italian region.
                All patients with major trauma (Injury Severity Score, >or=16) and severe head injury (Abbreviated Injury Scale score for the head, >or=4) rescued alive from March 1, 1998, to February 28, 1999, who received either form of care. Patients with self-inflicted injuries were excluded. The 184 patients who met the entry criteria were divided equally between care groups.
                None.
                Mortality at 30 days and Glasgow Outcome Scale score of survivors.
                After verifying the comparability of the cohorts, no survival or disability benefit could be demonstrated (95% confidence interval [CI] of the odds ratio for mortality [helicopter/ambulance] [95% CI 1], 0.72 to 2.67; 95% CI of the difference in Glasgow Outcome Scale score medians between helicopter and ambulance groups [95% CI 2], 0.0 to 0.0). Similar results were derived from analyses restricted to the subgroups identified by low (<or=90 mm Hg) roadside systolic blood pressure (95% CI 1, 0.58 to 7.17; 95% CI 2, -1 to 2) and by need for urgent neurosurgical intervention (95% CI 1, 0.16 to 2.60; 95% CI 2, 0 to 2). Exclusion from the ambulance group of victims rescued in urban areas did not change the results (95% CI 1, 0.80 to 3.24; 95% CI 2, 0.0 to 0.0). Stratification by age, Injury Severity Score, and Glasgow Coma Scale score demonstrated a small survival benefit (95% CI 1, 1.12 to 2.12) in the ambulance subgroup with Glasgow Coma Scale score from 10 to 12. Multiple logistic regression analysis confirmed that the group did not affect mortality.
                This study was conceived to emphasize the supposed advantages of the combined helicopter, physician, and advanced life-support rescue. No increased benefit compared with the simpler rescue group could be demonstrated. The mortality of 128 consecutive severely brain-injured patients (Glasgow Coma Score less than or equal to 8) treated by a land advanced life support system and transported to a trauma center was compared to the mortality of 104 consecutive severely brain-injured patients treated during the same time period by an advanced care rotorcraft aeromedical emergency service and transported to the same trauma center. The two patient groups had statistically similar distribution of CNS lesions and Glasgow Coma Scores. The mortality of the patients treated by the land ALS system was 40%. The mortality of the patients treated by the aeromedical service was 31%. The 9% reduction in mortality in the patients treated by the aeromedical service was statistically significant (p less than 0.001). There was also a statistically significant (p less than 0.05) reduction in the Glasgow Outcome Scores of the patients treated by the aeromedical service compared with patients treated by the land advanced life support system.
At this time, the evidence indicates that there is no benefit of advanced life support training for ambulance crews.