Improving trauma care in rural Iran by training existing treatment chains

Iran has a major land mine injury problem in its border areas. Mine injuries have a high mortality and morbidity, and the injuries generally occur in remote areas. Iran has a well developed system of rural health workers and clinics, covering most border areas. These have mainly had prevention, immunization and curative treatment for medical conditions as their focus. We hypothesized that adding a short training in trauma care to the already existing system of rural health workers would improve the care for trauma victims. The objective of the present study was to describe the training and evaluate its effect using mortality and change in physiological function of victims after prehospital treatment as outcome measures.

The training was arranged in villages and clinics in the border area. Physicians, nurses and emergency technicians from a local emergency clinic, the Mehran Clinic, were given a two-day course with monthly refreshers; while rural healthcare workers and lay people were given shorter training courses in their villages. All patients treated were registered and patients were followed up. Physiological changes after treatment was assessed with a modified three-component 'revised trauma score'. Patients entered the system directly through the local emergency clinic (some with prehospital treatment before arriving at the local emergency clinic). Some were transferred to the referral university hospital, and there they could be compared with a convenience comparison group of patients transported directly to the referral university hospital without treatment during transportation.

During the three-year study period 109 physicians, nurses and 76 emergency technicians (behwarses) were trained, while 4649 lay persons had first-responder training. A total of 366 patients were treated by the system. Prehospital support was given to 238 victims before admission to the primary clinic. We found no difference in mortality between patients with and without first-responder treatment. In all, 226 of these patients were transferred to the university hospital. During the period a group of 245 other victims of injury was admitted directly to the university hospital. The physiological status of the transferred victims improved significantly by treatment from the emergency clinic to the university hospital with a mean improvement in the Physiological Severity Score (PSS) of 1.11 (95% CI 0.98-1.24). The PSS of the intervention group was significantly higher than the status of the group brought directly to the university hospital without treatment during transportation (difference 0.73, 95% CI difference 0.55-.91, p < 0.0005).

We found that the existing rural healthcare system in Iran's western border area could be upgraded to care for mine victims and victims of other injuries by using available resources. This system improved the physiological status of the victims during transportation, and was able to handle penetrating as well as blunt injury. The use of existing health structures should be considered when planning improvements.