title: Prehospital trauma system reduces mortality in severe trauma: a controlled study of road traffic casualties in Iraq.
abstract: BACKGROUND
  In low-resource communities with long prehospital transport times, most trauma deaths occur outside the hospital. Previous studies from Iraq demonstrate that a two-tier network of rural paramedics with village-based first helpers reduces mortality in land mine and war-injured from 40% to 10%. However, these studies of prehospital trauma care in low-income countries have been conducted with historical controls, thus the results may be unreliable due to differences in study contexts. The aim of this study was to use a controlled study design to examine the effect of a two-tier prehospital rural trauma system on road traffic accident trauma mortality.
  
  
  METHODS
  A single referral surgical hospital was the endpoint in a single-blinded, non-randomized cohort study. The catchment areas consisted of some districts with no formal Emergency Medical Services (EMS) system, and other districts where 95 health center paramedics had been trained and equipped to provide advanced life support, and 5,000 laypersons had been trained to give on-site first aid. The hospital staff registered trauma mortality and on-admission physiological severity blindly. Assuming that prehospital care would have no significant impact on mortality in moderate injuries, only road traffic accident (RTA) casualties with an Injury Severity Score (ISS)≥9 were selected for study.
  
  
  RESULTS
  During a three-month study period, 205 patients were selected for study (128 in the treatment group and 77 in the control group). The mean prehospital transit time was approximately two hours. The two groups were comparable with regards to demographic characteristics, distribution of wounds and injuries, and mean anatomical severity. The mortality rate was eight percent in the treatment group, compared to 44% in the control group (95% CI, 25%-48%). Adjusted for severity differences between the treatment and control groups, prehospital care was a significant contributor to survival.
  
  
  CONCLUSIONS
  Where prehospital transport time is long, a two-tier prehospital system of trained paramedics and layperson first responders reduces trauma mortality in severe RTA injuries. The findings may be valid for civilian Emergency Medical Services interventions in other low-resource countries.
authors.affiliation: Trauma Care Foundation Iraq, Suleimaniah, Iraq.
authors.forename: Mudhafar Karim
authors.initials: MK
authors.lastname: Murad
authors.forename: Dara B
authors.initials: DB
authors.lastname: Issa
authors.forename: Farhad M
authors.initials: FM
authors.lastname: Mustafa
authors.forename: Hlwa O
authors.initials: HO
authors.lastname: Hassan
authors.forename: Hans
authors.initials: H
authors.lastname: Husum
mesh_terms: D000063:Accidents, Traffic / Q000401:mortality*; D000293:Adolescent; D000328:Adult; D002648:Child; D015331:Cohort Studies; D003625:Data Collection; D004632:Emergency Medical Services / Q000458:organization & administration*; D005260:Female; D006801:Humans; D015601:Injury Severity Score; D007493:Iraq / Q000453:epidemiology; D008020:Life Support Care; D016015:Logistic Models; D008297:Male; D009104:Multiple Trauma / Q000401:mortality; D016037:Single-Blind Method; D013997:Time Factors; D014187:Transportation of Patients