Trial lecture: An overview of pain relief in low and middle income countries, legislation, availability and governmental beliefs.
Ordinary opponents:
- First opponent: Associate Professor Lemlem Beza, Addis Ababa University, Ethiopia
- Second opponent: Professor Torben Wisborg, UiT The Arctic University of Norway
- Leader of the committee: Professor Ellen Karine Grov, OsloMet
Leader of the public defence is Associate Professor Dag Karterud, OsloMet.
Supervisors are Head of studies Trine Møgster Jørgensen, OsloMet and Associate Professor Fredrik Hetmann, OsloMet.
Thesis abstract
Prehospital care is one of the most critical pillars of emergency medicine and plays a fundamental role in patient survival.
Time-critical illness and trauma can cost life and limb if basic and/or advanced resuscitation and transport from the scene to the hospital are not correctly performed. Prehospital care also plays an essential role in treating larger groups of patients with common symptoms such as pain.
Most research in prehospital care is concentrated on time-critical illnesses and trauma. However, there is a paucity of research regarding prehospital care among vulnerable patient groups.
Aims
The overall aim of this thesis is to examine the prehospital care pertaining to the use of ambulance services and pain management among selected vulnerable patient groups across diverse health service resource settings.
The specific aims are:
- To describe the epidemiology of ambulance-utilized patients in Addis Ababa, Ethiopia
- To examine the prevalence of, and factors associated with, ambulance use in Addis Ababa, Ethiopia
- To examine the effectiveness and safety of paediatric prehospital pain medications across diverse health service resource settings
Methods
Studies one and two were conducted in Ethiopia's capital Addis Ababa. Both studies were designed as retrospective cross-sectional studies. Data were collected from medical patient records and retrieved from a public ambulance care provider and one public trauma center in Addis Ababa.
Trained data collectors entered all information using a pretested standardized abstraction format. Descriptive analysis and multivariable logistic regression were performed accordingly. Before they were conducted, the first two studies were approved by the Institutional Review Board (IRB) of St. Paul’s Hospital Millennium Medical College.
The last study was a systematic review based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The study was conducted on children under eighteen years of age with acute pain in the prehospital setting.
The preferred analgesics were reviewed based on the effectiveness and safety of the drug for prehospital pain management in children. Six electronic databases, including PubMed, Ovid Medline, Ovid Embase, CINAHL (Ebsco), Epistemonikos, and the Cochrane Library, were searched to retrieve available studies. Due to the heterogeneity of outcome variables, textual narrative analysis was performed.
Results
In study one, it was found that interfacility transfers (mainly pregnancy-related interfacility transfers) and clinically stable patients were the most frequent users of ambulances in Addis Ababa. The study also highlighted prolonged ambulance response time in Addis Ababa. The mean ambulance response time was more than eight minutes.
The second study found that the patient's acuity may influence the choice of transport at the scene of an accident in Addis Ababa. In this study, patients with high acuity were less likely to use an ambulance from the scene.
Moreover, many low-acuity patients referred from other health facilities were transported by ambulance. In contrast, one-third of moderate to high acuity patients arrived directly from the scene by other means of transport. Furthermore, among all patients referred from other health institutions, about 42.3 percent arrived at the trauma center without prior communication.
In the third study, a systematic review of eight studies revealed that fentanyl (intranasal/ IV), morphine (IV), methoxyflurane (inhalation), and combination preparations were effective analgesics for children in prehospital settings.
The study also found no serious adverse events related to the administration of the drugs studied (intranasal fentanyl, inhaled methoxyflurane, and IV /IM ketamine). In addition, the third study identified intranasal fentanyl and inhaled methoxyflurane as the preferred pain drug.
Conclusions
Accessible and equitable prehospital care development is fundamental for holistic emergency medical service. Vulnerable patient groups such as acutely sick patients living in Low-and Middle-Income Countries (LMICs) and children age group need special attention.
Inter-facility transfers and low-acuity patients were the dominant users of ambulance services in Addis Ababa. The response time of the ambulances was found to be prolonged. Since ambulance service is a resource-intensive medical service, a well-designed system that could prioritize the service for the most needed is essential.
Our systematic review also highlighted the effective and safe analgesic drugs for children in prehospital care. According to the current study, intranasal fentanyl and inhaled methoxyflurane seem to be the drug of choice due to the ease of administration, effectiveness, and safety of the drugs.
Perhaps these analgesics improve the quality of care for children in ambulances suffering from pain. However, the review only found level three and four evidence. Therefore, future research using high-level evidence designs such as randomized control trials is needed.
