title: Prehospital trauma system in a low-income country: system maturation and adaptation during 8 years.
abstract: BACKGROUND
  Of all deaths from injury, 90% occur in low- and middle-income countries, and most of the injured die before reaching a hospital. We have previously shown that a rural trauma system in Northern Iraq significantly reduced mortality in victims of mines and war injuries. In this follow-up study, we evaluated the adaptation and maturation of the system to changing injury patterns, focusing on mortality, time intervals from injury to medical help, and treatment effect on the physiologic impact of injuries.
  
  
  METHODS
  Approximately 6,000 first responders and 88 paramedics were trained in Northern Iraq from 1996 to 2004 and treated 2,349 victims. All patients were prospectively registered with monitoring of time intervals, interventions performed, prehospital treatment effect, and mortality.
  
  
  RESULTS
  Injury pattern changed markedly during the study period, with penetrating injuries decreasing from 91% to 15%. Mortality in victims of mines and war injuries (n = 919) decreased from 28.7% to 9.4% (p = 0.001), as did the time interval from injury to first medical help, from 2.4 hours to 0.6 hours (p = 0.002). The prehospital treatment effect improved significantly in the later part of the study period compared with the first years (p < 0.0005). Improvement was maintained in new injury groups. Retention of paramedics in the program was 72% after 8 years.
  
  
  CONCLUSIONS
  This low-tech prehospital emergency system designed for dealing with penetrating trauma matured by reducing time to first medical help and by improving physiologic parameters after prehospital treatment during the 8-year study period. The program adapted to changing injury patterns without compromising results.
authors.affiliation: Department of Anesthesiology and Intensive Care, Hammerfest Hospital, Hammerfest, Norway. torben.wisborg@helse-finnmark.no
authors.forename: Torben
authors.initials: T
authors.lastname: Wisborg
authors.forename: Mudhafar K
authors.initials: MK
authors.lastname: Murad
authors.forename: Odd
authors.initials: O
authors.lastname: Edvardsen
authors.forename: Hans
authors.initials: H
authors.lastname: Husum
mesh_terms: D015998:Abbreviated Injury Scale; D000328:Adult; D000488:Allied Health Personnel / Q000193:education*; D004632:Emergency Medical Services / Q000458:organization & administration* / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D007493:Iraq / Q000453:epidemiology; D008297:Male; D012372:ROC Curve; D012424:Rural Population; D013997:Time Factors; D014857:Warfare; D014947:Wounds and Injuries / Q000145:classification / Q000453:epidemiology / Q000628:therapy*