Prehospital Care for Road Traffic Injury Victims

Abstract

Introduction:

Prehospital capabilities are inadequately developed to meet the growing needs for emergency care in most low- and middle-income countries. This study aims to describe the prehospital care received by the road traffic injury (RTI) victims presenting to a level I Trauma Care Center in Central Kerala, India.

Methods:

This was a hospital-based prospective observational study, which included consecutive victims of RTI attending the emergency department within 24-h of the event. A structured interview schedule was developed for collecting the data on various domains and the patients were followed up for their duration of hospital stay.

Results:

A total of 920 RTI victims, were included in this study. Two percent (17/920) of first responders had some sort of training in trauma care whereas the rest were untrained. The time taken to get any help at the scene after an RTI was 8 ± 12.9 min (95% confidence interval [CI] 7.16–8.84) and for first medical contact 25 ± 16 min (95% CI 24–26). No attempt at field stabilization occurred in any case. Three percent (26/920) had received some form of prehospital care, like arrest of hemorrhage using a compression bandage and splinting of the fractured limb with a wooden plank. None of the patients received supplemental oxygen, airway management, or cervical spine immobilization at the site of the accident or en route to the hospital.

Conclusion:

A lack of an organized prehospital care system results in minimal care before hospital admission. Urgent establishment of ambulance services and structured prehospital care tailored to our health-care system is imperative.

INTRODUCTION

Trauma management is a neglected field in developing nations.[1] According to the World Health Organization’s global status report on road safety, road traffic injuries (RTIs) are responsible for approximately 1.35 million fatalities worldwide each year, with India alone accounting for 150,000 of these deaths.[2] An overwhelming proportion of these deaths occur before patients even reach the hospital in low- and middle-income countries (LMIC). Notably, a significant portion of prehospital trauma deaths, up to 47.6%, could be prevented.[3,4] These fatalities are frequently due to failures in managing airways, respiratory issues, or ongoing bleeding, which could be avoided with effective prehospital and early hospital emergency care.[3] However, prehospital trauma care has been inadequate due to the high costs of resuscitation and lack of trained people in emergency medical service (EMS).[5,6] Furthermore, there are limited data on the effectiveness of prehospital care in India.[7,8,9,10] This study aims to describe the prehospital care of RTI victims presenting to a Level 1 Trauma Care Center in India and to investigate the association between prehospital interventions and patient outcomes.

METHODS

Study design

This was as a hospital-based prospective observational study from January 2019 to April 2019.

Setting

Consecutive sampling of RTI victims presenting to the emergency department (ED) of, (Jubilee Mission Medical College and Research Institute), a level one Trauma Care Center[5] in (Thrissur), was done till the required sample size was realized. The required sample size was achieved in 4 months (January 2019–April 2019). The preliminary situational analysis in terms of the epidemiology of RTIs and trauma care facilities available in the district was done as part of a multicentric study.[8,11] A structured interview schedule was developed for collecting relevant data. The data were collected from the patient (if coherent) or prehospital immediate care provider. Data were also obtained and cross-referenced from patient records and the pro forma filled by the attending doctors on duty. The follow-up of cases was done until discharge from the hospital or up to 30 days, whichever was earlier.

Inclusion criteria

All patients with RTI presenting to ED within 24 h of injury were approached to be recruited for the study.

Exclusion criteria

The individuals who did not consent to be part of the study or withdrew their consent later on were excluded. We also excluded cases where prehospital care providers could not be traced or where any reliable or meaningful data could not be collected even after repeated interviews [Figure 1].

Figure 1.

Flow diagram: Selection and exclusion of road traffic injury victims. RTI: Road traffic injury, ED: Emergency department

The study limited its focus to the first 24 h postinjury to ensure a consistent, comparative analysis of the critical early phase of prehospital care for RTI victims, where immediate intervention is vital and recollections are most reliable.

Consent

Written informed consent was obtained from all the patients or their legally authorized representative (LAR) included in the study.

Study size

Initially, a pilot study was conducted, enrolling a smaller cohort (n = 20) of RTI victims. Based on the proportion of patients recruited in the pilot study, with 95% of a confidence interval (CI) and 20% of allowable relative error, the minimum sample size was calculated to be 777 using the formula: n = (Z_1-α/2)² (pq)/d², where, n = sample size, Z = z-score associated with a level of confidence, P = sample proportion, and d = margin of error.

To account for a presumed 15.5% nonresponse rate based on the initial pilot, the adjusted sample size was recalculated using the formula n’ = n/1 − p where, n’ = adjusted sample size, n = original sample size (777), and P = presumed nonresponse rate (0.155). The recalculated sample size was 919.52, which was rounded up to 920 participants.

Statistical methods

The statistical software, namely, Statistical Package for the Social Sciences, SPSS (International Business Machines Statistical Package for the Social Sciences, IBM Corp. Released 2013, version 22.0. Armonk, NY, USA: IBM Corp) was used for the analysis of the data. Microsoft Word and Microsoft Excel (2013 version) were used to enter data and generate graphs, tables, and charts. Numerical variables are expressed as mean ± standard deviation (95% CI, minimum [min]-maximum [max]). Categorical variables are expressed as percentages (number and fraction).

RESULTS

Epidemiology

A total of 976 RTI victims were approached to participate in the study. Twenty-seven patients arrived after 24 h of the incident. Data were not available for 28 individuals and one withdrew consent. Finally, data from 920 participants who met the recruitment criteria were included for analysis [Figure 1].

The study predominantly involved male RTI victims (75.7%, 697 males) with a mean age of 36.6 years (±17.4 years, range 1–87). RTI was more in the rural area 68.36% (n = 629) predominantly involving motorbikes (80.7%, n = 742). The majority of RTI victims were drivers (59%), followed by pillion riders (21.6%) and pedestrians (11.1%) [Table 1]. Among motorbike accident victims (n = 585), only 50.5% of riders wore helmets, with no pillion riders wearing helmets, and in car accidents (n = 66), 33% of individuals used seat belts.

Table 1.

Demographic and incident characteristics of road traffic injury victims presenting to the emergency department

Data head	Subgroup	n (%)
Place of accident	Urban	291 (31.64)
	Rural	629 (68.36)
Type of vehicle	Motorized two wheeler	742 (80.7)
	Motorized three wheeler	55 (6.0)
	Car	66 (7.2)
	Heavy transport vehicle	13 (1.4)
	Pedal cycle	25 (2.7)
	Bus	11 (1.2)
	Pick up van	5 (0.5)
	Unknown	3 (0.3)
Patient position	Driver	543 (59.0)
	Pillion rider	199 (21.6)
	Pedestrian	102 (11.1)
	Front seat passenger	18 (2.0)
	Rear seat passenger	38 (4.1)
	Other passenger (e.g., in a bus)	12 (1.30)
Safety measures: Helmet or seat belt	Two wheeler passenger with helmet	302 (32.8)
	Two wheeler passenger without helmet	372 (40.3)
	Car passenger with seat belt	22 (2.30)
	Car passenger without seat belt	22 (2.3)
	Pillion rider	196 (11.1)
PHN	Yes	4 (0.4)
	No	916 (99.6)
Type of collision	Skid	167 (18.2)
	Hit from side/T bone collision	189 (20.5)
	Hit fixed object	84 (9.1)
	Fall from moving vehicle/ejection	48 (5.2)
	Hit pedestrian	141 (15.3)
	Head on collision	142 (15.4)
	Hit animal	9 (1.0)
	Rear ended/nose to tail collision/hit from back	60 (6.5)
	Toppled over	22 (2.4)
	Unknown	45 (4.9)
	Fall from height	5 (0.5)
	Others	8 (0.9)
Risk factors	Alcohol	134 (14.6)
	Data not available	768 (83.6)
	Sleeping	15 (1.6)
	Over speed	5 (0.5)
First responders	Passerby	559 (60.8)
	Occupant of opposite vehicle	191 (20.7)
	Bystander	39 (4.2)
	Ambulance driver	95 (10.2)
	Police	4 (0.4)
	Self	7 (0.8)
	Friends/family	24 (2.6)
Training in trauma care	Yes	17 (1.3)
	No	903 (98.2)
Mode of transport	Motorized three wheeler	489 (53.2)
	Car	283 (30.8)
	Ambulance	95 (10.3)
	Motorized two wheeler	44 (4.8)
	Police vehicle	5 (0.4)
	Other	4 (0.4)
Any prehospital care	Airway	0
	Cervical spine immobilization	0
	Oxygenation or ventilation	0
	Active hemorrhage control	17 (1.8)
	Splinting	9 (0.97)

PHN: Prehospital notification

Severity of injury

The severity of injury at admission was graded using injury severity scoring (ISS). ISS was mild in 747 (81.1%, 747/920), moderate in 37 (4.02%, 37/920), and severe in 36 (3.9%, 36/920). In patients with mild ISS score, there were two deaths (0.26%, 2/747); one due to pulmonary embolism and one ventilator-associated pneumonia. Among them, 14 patients received some sort of prehospital care (1.87%, 14/747). In moderate ISS scores, there were two deaths (5.4%, 2/37); one brain stem injury and one ventilator associated with pneumonia. Six (16.21%, 6/37) of them received minimal prehospital care in the form of hemorrhage control and splinting; there was one death due to severe TBI. There were 21 deaths among the victims who had severe ISS scores (58.3%, 21/36) and none of them received prehospital care.

Prehospital notification and prehospital care

Out of the 920 RTI victims, only 4 received prehospital notification (PHN) (0.4%). In all four of these cases, ambulance personnel initiated the notification to the first medical contact (FMC). A call for help from the site of the accident was made by the victim in 25.5% (235/920) of cases and the passer by in 74.5% (685/920).

Eighty-nine percent, called for help by drawing attention from passerby and 11.3% (n = 104) called for help using a mobile phone and 0.8% (n = 7) of victims came on their own. The mean time for any response after the call was 8+/12.9 min (95% CI, 7.16–8.84) and the mean time of arrival to FMC was 25 ± 16 min (95% CI, 23.45–25.63). Ninety-eight percent (905/920) of the patients could reach the primary care center in the golden hour. Less than two percent (18/920) of the first responders reported having “some training” in prehospital care. Victims at the site or during transportation to the hospital received little prehospital care.

Motorized three-wheelers were the predominant mode of prehospital transport for RTI victims (53.2%, n = 489), followed by cars (30.8%, n = 283), and ambulances (10%, n = 95). Of the 45 patients who required emergency intubation at the hospital, none received prehospital airway management, and 15 (33.3%) subsequently died. No cervical spine motion restriction was provided for the 12 patients with fractures, even for the 4 (33.3%) transported by ambulance. Among the 75 (8.2%) patients, hypoxic upon ED admission, none received prehospital oxygen, including the 17 (22.7%) transported by ambulance. Only 17 (10.6%) of the 160 patients with active bleeding received prehospital hemorrhage control, and a mere 9 (5.2%) out of 173 requiring splinting for long bone fractures received immobilization before reaching the hospital, with 5 of the splinted patients dying and another 5 requiring a prolonged intensive care unit (ICU) stay [Table 1].

The absence of critical prehospital care, specifically supplementary oxygen (P ≤ 0.000) and airway management (P ≤ 0.000), cervical spine motion restriction (P ≤ 0.000), and hemorrhage control (P = 0.003), was significantly associated with increased rates of prolonged ICU stays and mortality among RTI victims [Table 2].

Table 2.

Clinical findings requiring emergency department interventions among road traffic injury victims and their association with intensive care unit stay and mortality

Intervention/clinical findings	ICU stay				Mortality
	Yes, n (%)	No, n (%)	χ 2	P	Yes, n (%)	No, n (%)	χ 2	P
Airway management
Required but not done (45)	35 (77.7)	10 (22.2)	53.4	0.000	15 (33.3)	25 (55.5)	293.4	0.000
Not required (875)	224 (25.6)	651 (74.4)			4 (0.45)	871 (99.54)
Cervical spine motion restriction
Required but not done (124)	103 (83.06)	21 (16.93)	216.4	0.000	12 (9.7)	112 (90.3)	26.3	0.000
Not required (796)	154 (19.34)	642 (80.6)			13 (1.6)	783 (98.4)
Supplementary oxygen
Required but not administered (74)	57 (77.02)	17 (22.9)	53.4	0.000	15 (20.2)	59 (79.72)	182.7	0.000
Not required (846)	201 (23.7)	645 (76.24)			5 (0.59)	841 (99.40)
Hemorrhage control
Done/attempted in the prehospital setting (17)	3 (17.6)	14 (82.4)	11.8	0.003	0	17 (100)	5.4	0.067
Required but not done/attempted (143)	24 (16.8)	119 (83.2)			0	143 (100)
Not required (730)	230 (30.3)	530 (69.7)			25 (3.3)	735 (96.7)
Splinting
Required but not done (177)	46 (26)	131 (74)	0.412	0.576	5 (2.8)	172 (97.2)	0.010	0.922
Not required (743)	211 (28.4)	532 (71.6)			20 (2.7)	723 (97.3)
Total (920)	257 (270.90	663 (72.1)			25 (2.7)	895 (97.3)

ICU: Intensive care unit

DISCUSSION

By 2030, road traffic crashes are predicted to be the eighth leading cause of death and the fourth leading cause of disability-adjusted life-years worldwide.[12] Prehospital care has a vital role in the initial management of a patient in polytrauma.

Call for help

Prehospital care should begin from the moment an accident occurs. In Western Countries, most EMS have a common number to initiate the service.[13] In the United States, Mexico and Canada, dialing “9-1-1” from any telephone will link the caller to an emergency dispatch office – called a Public Safety Answering Point by the telecommunications industry – which can send emergency responders to the caller’s location in an emergency.[14] Across the globe, the north American emergency phone number “911” is recognized as a call center number for emergencies, whereas in most LMIC, a single number is usually not available. Multiple confusing, and often hard to remember numbers, unique to individual ambulance service providers and hospitals exist in the region making it difficult to get appropriate medical help at the site of a road crash.[15,16] Often ideas which have been implemented with best intentions like the National Highway Authority of India emergency communication - ”emergency communication boxes” [Figure 2] across the state highways are unused either due to lack of awareness or poor maintenance.

Figure 2.

National Highway Authority of India emergency communication - ”emergency communication boxes”

“First” responders: Who came to help?

The first person to reach any site of disaster would be the nearest by proximity to the event. In most settings where a prehospital trauma care system does not exist, the initial care of the victim is taken over by the citizens and community members at the scene. The priority of the public who gather around the crash site is to transport the victims to the nearest medical facility at the earliest.[10] Although a priority, if it interferes with the timely performance of crucial trauma care measures such as protecting the airway or minimizing an ongoing hemorrhage, it may adversely affect the outcome. A majority of “first” responders in this study were lay rescuers with no training in first aid or trauma care.

How did they transport

In rural areas, the mode of transport plays a significant role in prehospital care as the FMC may be far away from the highways where high-velocity motor vehicle crashes occur. The locally available mode of transport is used to get the victims to a hospital without delay.[16,17,18,19]

In our study, we noted that many of the victims were transported by motorized three-wheelers and cars (53.2% and 30.8%, respectively). Motorized three-wheelers, locally known as “autorickshaws,” in both rural and urban settings in India, are the most commonly accessible mode of transport and often the first on the scene.[19] Targeted education of autorickshaw drivers across the nation may be a practical solution in our setting to improve prehospital care.[20] Transporting the RTI victims in nonambulance vehicles such as motorized three-wheelers has been theorized to pose a serious threat in the form of worsening of spine injury.

Only 10% of the victims were transported by ambulance. These ambulances had limited infrastructure with no trained person other than the driver. The ambulances in the region that can provide advanced life support (ALS) to the RTI victim are restricted to inter-hospital transport. At times, they may pick up a person on their usual run. For instance, in this study, two victims were brought on an ALS ambulance that was transporting a snakebite victim to the institute.

Prehospital notification

Any forewarning of the arrival of a patient to a hospital, in this study, was considered as a PHN. PHN aids the hospital to be prepared to provide emergency care to RTI victims or to redirect them to an appropriate facility according to the patient’s condition.[21] In our study, PHN was noted in <1% (n = 4, 4/920) cases. Hospitals in the region have individual contact numbers for notification, which makes it virtually impossible for most of the onlooker-initiated transport to forewarn the hospitals.

Care provided before reaching first medical contact

We tried to find out about the care given to the RTI victims at the crash site or during the transport to FMC by interviewing either the bystander or the care provider when they reached our ED with the RTI victim using a preset pro forma. We also recorded the findings during the primary survey performed on the RTI victims which again provided clues regarding the prehospital care. We assessed the prehospital care under the following headings as we assessed the patient in the emergency room.

Airway

Forty-five individuals required emergency endotracheal tube placement in ED in our study. None of these patients received any prehospital airway management at the site or en route. Prehospital airway intervention has been shown to improve neurological outcomes in severe head injury.[22,23] Among the patients who required emergent airway management in ED, 15 (33%, 15/45) died and the cause of death postmortem was attributed to severe traumatic brain injury. Whether airway management in the prehospital setting would have improved their outcome is something that warrants further investigation.

C spine

Hundred and twenty-four RTI victims were found to have a cervical spine fracture on evaluation in the ED. None of them had their cervical spine motion restriction in the prehospital settings. In a setting where < 10% of the victims are transported by an ambulance, no prehospital assessment or physical examination is expected. It is to be noted that out of the 124 patients with cervical spine fractures detected on admission, six were transported by an autorickshaw. Twelve out of 124 victims with cervical spine fracture had associated severe traumatic brain injury which was the primary cause of death. The existing evidence for routine use of the cervical collars in the prehospital setting is weak.[24] Whether scoop-and-run policy practiced in a resource-limited setting by the onlookers leads to better patient outcomes warrants further multicentric prospective evaluation.

Breathing and ventilation

None of the patients’ vitals were checked and recorded from the site of RTI or during transport even while being transported on an ambulance (n = 95, 10%). Oxygen saturation was recorded as low (≤94%) at admission for 74 patients warranting supplemental oxygenation at the time of arrival. In a resource-limited setting, minimal interventions such as prehospital monitoring of SPO₂ and administration of supplemental oxygen may have a role in improving patient outcomes. In contrast to Western settings where the unchecked usage of oxygen leading to hyperoxia is a concern in the prehospital environment, in our region, the failure to administer oxygen when needed poses a greater risk.[25] Even though some patients were brought in an ambulance that had oxygen supply, they were not given it because there was no additional trained staff to care for the patient.

Hemorrhage control and immobilization

A delay in controlling bleeding is often the cause of many preventable deaths in RTI. Of the 920 participants, only <2% had received some form of prehospital care like the arrest of hemorrhage by a cloth or splinting of the fractured limb with a wooden plank. A recent study from Ghana showed that due to the lack of training, participants had devised various strategies to assist RTI victims, which likely resulted in further injuries and even the death of the victims.[26]

Although over the years trauma institutes and emergency ambulance services have been established in developing nations, most of them remain confined to the urban pockets with minimal efforts to expand the system into rural areas.[27] Trauma-care systems in India are at a nascent stage of development. Prehospital care is virtually nonexistent in most rural and semi-urban areas in India, and implementation of the “golden hour” concept is still an unachieved goal. Although Kerala is one of the leading states in health care and literacy in India, the prehospital care system in the region is still in its infancy. Even though the state made some efforts to make available EMSs to people under various schemes, the desired results are yet to be achieved.

Limitations

Even though all efforts were made to minimize recall bias, it was inevitable that the data collection occurred in the hospital rather than in the prehospital setting. Our study’s categorization of “training in trauma care” was based solely on self-reported data without detailed verification, which may not accurately reflect the complexity and adequacy of the training received by the first responders. Real-time prehospital, prospective data collection may be needed to assess with certainty the state of the prehospital trauma care in the region. While the external validity of this study may be questioned because it is a single-center study and its results may not be generalizable to the entire nation, to our knowledge, this is the first study to comprehensively assess prehospital care for RTI victims in the region.

In addition, while our study has revealed significant associations between the absence of specific prehospital interventions and increased rates of prolonged ICU stays and mortality, it is crucial to acknowledge that these associations do not imply causation. The Chi-square tests indicate statistical significance but do not establish direct causal relationships.

Furthermore, while we accounted for injury severity in our analyses, other potential confounding factors that could influence patient outcomes, such as preexisting health conditions or the specifics of the prehospital care provided, were not fully explored.

CONCLUSION

Kerala has carved a notable niche on the global health map owing to the ready access of health services in the state. However, RTI victims receive minimal care before reaching the hospital and no systematic EMS exists in the region. Patients are mostly brought to the hospital by untrained laypersons utilizing passing vehicles. This study, the first ever of its kind in Kerala, necessitates the need for taking urgent steps for establishing ambulance services, prehospital care, and trauma services in Kerala. Emphasis must be given to training laypersons as the first responder systems in the communities. In addition to this, unique regional models should be developed to address the needs of the trauma patient globally especially in LMIC.

Research quality and ethics statement

This study was approved by the Institutional Review Board (IEC:36/18/IEC/JMMC&RI). The authors followed applicable EQUATOR Network (https://www.equator-network.org/) guidelines during this research project.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.

SUPPLEMENTARY FILES

ANNEXURE

Data collection proforma

1. Biodata

   • 1.1.Name:
   • 1.2.Age:
   • 1.3.Hospital No
   • 1.4.Gender: ϒ Male ◯ Female ◯ Others

2. Prehospital Notification

   • 2.1.PHN received ◯ Yes ◯ No
   • 2.2.Date of PHN (dd/mm/yyyy): __/__/____
   • 2.3.Time (__: __):__: __ ◯ am ◯ pm
   • 2.4.Prehospital data provider:
     ◯ Patient ◯ Patient relative ◯ Unrelated Onlooker ◯ Police ◯ Ambulance personnel ◯ Fire and Rescue ◯ First Medical Contact (over phone)

3. Injury Event Data

   • 3.1.Date of RTI (dd/mm/yyyy): __/__/____
   • 3.2.Time (__: __):__: __ ◯ am ◯ pm

4. Place of injury: _______

   ◯ Urban:	◯ Rural:
   ◯ High capacity urban road	◯ State highway
   ◯ Street	◯ National highway
   ◯ Other	◯ Other
   ◯ Unknown	◯ Unknown
   ◯ Not recorded	◯ Not recorded

   If other please specify: ______________

5. Primary vehicle:

   • ◯ Pedal-cycle ◯ Motorized 2 wheeler ◯ Motorized-3 wheeler ◯ Car ◯ Pick up–Truck/Van ◯ Heavy transport vehicle ◯ Bus ◯ Spl.Industrial vehicle ◯ Spl.construction vehicle ◯ Unknown ◯ Other ◯ Not recorded
     If other please specify: ______________

6. Patient role

   • ◯ Driver ◯ Front seat passenger ◯ Rear seat passenger ◯ pillion rider ◯ Other passenger (bus/pick-up) ◯ Pedestrian ◯ Unknown ◯ not recorded
     Helmet/Seat belt: ◯ Yes ◯ No ◯ Not applicable ◯ Not recorded

7. Type of collision ◯ Hit pedestrian ◯ Head on collision ◯ Hit from back ◯ Skid Hit from side

   • ◯ Nose to tail collision ◯ Hit and run ◯ Hit fixed object ◯ Hit animal ◯ Overturn ◯ Fall from moving vehicle ◯ Trapped between two vehicle ◯ Others ◯ Unknown ◯ Not recorded

8. Dominant type of injury ◯ Blunt ◯ Penetrating ◯ Mixed

9. Associated Risk factors

   ◯ Alcohol ◯ Texting ◯ Music ◯ Over speeding ◯ Talking on phone ◯ Not recorded ◯ Not applicable ◯ Other

10. Who Called for help?

    • 10.1. ◯ Victim ◯ Bystander
    • 10.2. How did you call for help: ◯ Mobile phone ◯ Screamed
    • 10.3. Which number was contacted: Please specify: ◯ 100 ◯ 108 ◯ 101others: _______
    • 10.4. Time when called for help: ___:___

11. Call responded by

    • 11.1. ◯ Passer-by ◯ Ambulance personnel ◯ Police ◯ Fire and Rescue ◯ Other
      If other please specify: ______________
    • 11.2. First response to call for help: ◯ Help was prompt ◯ Help was delayed
      11.3. If delayed please specify reason for delay: ______________
      ◯ Mobile phone connectivity ◯ Unwillingness of passerby to help

12. Profile of pre hospital care provider:

    • 12.1. Education: ◯ Illiterate ◯ Primary education ◯ Upper primary ◯ Higher secondary/Predegree ◯ Graduate or higher
    • 12.2. Occupation ◯ Professional ◯ Nonprofessional. Specify: _______________________
    • 12.3. Training in Trauma care/Accident ◯ Yes ◯ No

13. Care provided at the site and Transport

    • 13A. Airway Maintenance with restriction of cervical spine Motion
      • 13A.1. Airway managed ◯ Yes ◯ No
      • 13A.2. Suction Done ◯ Yes ◯ No
      • 13A.3. Jaw thrust and chin lift ◯ Yes ◯ No
      • 13A.4. Oropharyngeal airway ◯ Yes ◯ No
      • 13A.5. C-Spine stabilized: ◯ Yes ◯ No
    • 13B. Breathing and Ventilation
      • 13B.1 Oxygen supply ◯ Yes ◯ No
      • 13B.2. Use of pulse oximetry ◯ Yes ◯ No
    • 13C. Circulation with hemorrhage control
      • 13C.1. Assessment of vital signs BP/Pulse rate ◯ Yes ◯ No
      • 13C.2. Data available: ◯ Yes ◯ No
      • 13C.3. Active hemorrhage control: ◯ Yes ◯ No
      • 13C.4. Compression bandage applied ◯ Yes ◯ No
    • 13D. Disability
      • 13D.1. GCS score ◯ Yes ◯ No
      • 13D.2. Alert ◯ Yes ◯ No
      • 13D.3. Verbal ◯ Yes ◯ No
      • 13D.4. Pain ◯ Yes ◯ No
      • 13D.5. Unresponsive ◯ Yes ◯ No
    • 13E. Exposur
      • 13E.1. Hypothermia prevented × ◯ Yes ◯ No
      • 13E.2. Immobilization Splinting of Limbs: ◯ Yes ◯ No

14. Transport

    • 14.1. Scoop and Run
    • 14.2. No one stopped for a while
    • 14.3. Time vehicle arrived at the site (___: ___) ◯ am/ ◯ pm
    • 14.4. Type of vehicle: ◯ Pedal-cycle ◯ Motorized 2 wheeler ◯ Motorized-3 wheeler ◯ Pick up –Truck/Van ◯ Heavy transport vehicle ◯ Bus ◯ Car ◯ Ambulance
    • 14.5. Type of Ambulance
      BLS - ◯ patient bed pulse oxymetry ◯ O2 devices
      ALS ◯ Ventilator ◯ Cardiac monitor ◯ Paramedic staff ◯ ECG ◯ Patient transport Vehicle
    • 14.6. Arrival to JMMC Time (___: ___) ◯ am/ ◯ pm

15. Primary survey

    • 15A. Airway
    • 15A.1 Patent ◯ Yes ◯ No
      If no
    • 15A.2 ◯ Suction ◯ OPA ◯ Definitive airway in situ
    • 15A.3 C-Spine stabilized: ◯ Yes ◯ No
    • 15B. Breathing 15B. 1SPo₂ maintaining ◯ Yes ◯ No
      If no 15B.2 ◯ Face mask ◯ NRBM ◯ Nasal cannula
    • 15C. Circulation 15C.1. BP/PR stable ◯ Unstable
    • 15C.2 Hemorrhage control
    • 15C.3 IVF
    • 15C.4 Blood transfusion
    • 15D. Disability 15D.1 GCS score ◯ Yes ◯ No
    • 15D.2. Alert ◯ Yes ◯ No
    • 15D.3. Verbal ◯ Yes ◯ No
    • 15D.4. Pain ◯ Yes ◯ No
    • 15D.5. Unresponsive ◯ Yes ◯ No
    • 15E. Exposure 15E.1. Hypothermia prevented ◯ Yes ◯ No
    • 15E.2. Decontamination ◯ Yes ◯ No
    • 15E.3. Warming ◯ Yes ◯ No

16. Course in the hospital

    • 16.1. No days in the hospital __________________
    • 16.2. No of days in ICU __________________
    • 16.3. No of days on ventilator ____________________
    • 16.4. Any adverse events ____________________

17. Final disposition

    • 17.1 ◯ Discharged home
    •    ◯ Transfer to other hospital
    •    ◯ Residential aged care services or nursing home
    •    ◯ Death
    •    ◯ Abscond
    •    ◯ DAMA
    •    ◯ Other
    •    ◯ Not recorded
    • 17.2.1. Hospital disposition date (dd/mm/yyyy): __/__/____
    • 17.2.2. Hospital disposition Time (__: __):__: __ ◯ am◯ pm