Prehospital Trauma Care Education Using Innovative Pedagogy for Rural Texas Trauma Care

Background: Morbidity and mortality for trauma accidents in rural settings is nearly three to six times as high as in urban settings in the United States. In both developed and developing countries, most morbidity due to trauma occurs in the prehospital period. This increase in morbidity and mortality is in part, due to a lack of appropriate critical care education of first responders in rural settings. We sought to address this issue by increasing the number of trained first responders as well as to assess the confidence and competency of participants’ trauma management skills. The Vyas Global Prehospital Education Initiative (VGPEI) aims to address this problem through implementation of a four-tiered trauma education program, which incorporates high-fidelity simulation, video-recorded debriefing,


General Background
Trauma is a leading cause of death worldwide and is particularly prevalent and troubling in the United States. The "Golden Hour" in trauma has long been cited as the critical goal to reduce morbidity and mortality. However, there is increasing evidence to suggest not only that this benchmark may not be as ideal as previously thought, but also that many Americans face significant geographical barriers in receiving trauma care in this timeframe [1][2][3][4][5][6]. This disparity in care can be viewed in Figure 1, showing the vast areas of West Texas that are not within a 1 hour driving distance to a Trauma Center [5].
With increasing evidence suggesting that with appropriate training, civilians can safely administer basic prehospital care, there is clear need for effective training of large portions of the population as a strategy to improve prehospital trauma care, and ultimately, traumarelated morbidity and mortality [5]. Prehospital trauma care first became an area of major focus for the medical community during the Vietnam War, after noting marked improvements in battlefield injury outcomes related to improved hemostatic intervention and transport systems [6,7]. Improved structure of trauma systems has been noted to both decrease time to definitive care as well as trauma outcomes [6]. However, especially in sparsely populated and remote areas, the need for on-site intervention by bystanders is an area that could greatly improve trauma outcomes by stabilizing the patient, and potentially extending the traditional golden hour [1].

Results:
The change in confidence of medical students was significant; t(8)=0.005, p=0.013. While no other groups showed significant changes in competence or confidence, there was demonstrated improvement in all groups.

Conclusion:
The initial assessments point towards the First Responder Trauma and Emergency Care Program being a worthwhile effort in the West Texas region. This pilot study also shows that despite a small sample size showed an upward trend in confidence and competence attainment and are likely effective in improving confidence and competence of first responders, but further studies are needed to assess whether this program produces a significant difference in these areas. Future efforts will include recreation of this session in the cities of Lubbock and Amarillo, further analysis of data points collected from these additional sessions, and determination of what additional locations would benefit from these sessions in addition to analysis of the efficacy of the program in improving trauma care. Therefore, a prehospital trauma care training program has the potential to spread these skills to a much broader cohort than the traditional medical community and to provide greater trauma care coverage to all citizens, especially those in underserved areas. Many models of prehospital care promote the use of first responders [8].
Two complimentary approaches, designated Tier 1 and Tier 2 care, have been suggested by the WHO in their publication, "Prehospital Trauma Care Systems". Tier 1 denotes individuals without formal Training, such as bystanders. Tier 2 indicates the use of formally medically trained personnel. This study specifically addresses the prehospital period denoted by Tier 1.

Relationship of Confidence to Bystander Effect
Some estimates place the portion of the world's population living in areas without access to formal EMS at 50-75%. This means that the use of Tier 1 individuals could have broad effects on prehospital morbidity and mortality outcomes [8]. The creation groups of Tier 1 responders via training resources in basic first aid and trauma care techniques via mobilization of community members could be one way of accomplishing this. Previous studies have shown that many (83%) of bystanders are willing to perform lifesaving skills (i.e. CPR) in emergency situations such as Cardiac Arrest [9]. Of the respondents not willing to perform these skills, they cited lack of confidence as a barrier [9]. By simply strengthening the confidence of bystanders via education and training, a direct increase in willingness to provide emergency care has been previously shown [1].

Pedagogical Efficacy in Relation to Traditional Training Programs
In a previous literature review, several themes were found to be common amongst trauma education initiatives directed towards layperson first responders [2] These included assessing existing resources, adapting existing resources to optimally educate laypersons, tailoring training methods to low or variable education and literacy levels, and a post-training method of assessment. Of note was that the optimization of technology for remote use was found to be particularly valuable in low resource settings. The

Million Life Fighters Campaign implemented via the Vyas Global
Prehospital Education Initiative (VGPEI) proposes and implements a novel four-tiered trauma training protocol that can address the gaps in existing trauma training protocols. These existing protocols become particularly problematic in low-resource settings [9].
VGPEI takes an innovative approach to trauma skill education by implementing a program that accommodates educational and socioeconomic diversity, which prioritizes utilizing layperson language, accessibility, cost-effectiveness and high-fidelity simulation training [3]. This program was initially implemented in a large police training center in Jodhpur, India and showed promising efficacy in improving competence and confidence.

General Goals and Future Direction
Limited evidence exists regarding prehospital training and outcomes, but in limited data among medical personnel, simulation training improves confidence in performing prehospital care [4].
In more directed study, a precursor curriculum to the one studied showed statistically significant improvement competence increases in all areas of trauma management tested [10]. The need for prehospital training, lack of sufficient coverage by trauma centers and medical personnel, and evidence to suggest that training is a serviceable way to transfer prehospital care skills necessitate that the medical community make use of the opportunity to spread prehospital care skills to as many people as possible.

Traditional trauma training programs such as Advanced Trauma
Life Support (ATLS), International Trauma Life Support (ITLS), and Basic Life Support (BLS) have proven ineffective as conduits to transfer trauma skills to civilians [1]. In our training paradigm, we have introduced a four-tiered program that consists of Acute

Trauma Training (ATT), Broad Trauma Training (BTT), Cardiac
Trauma Training (CTT), and Massive Open Online Course (MOOC) Trauma Training [3]. Traditional trauma training paradigms are designed to complement medical education, and therefore are ill-suited for use as curriculum structures for the general public [3]. Previous studies have shown the efficiency and efficacy of lay trauma training and provide foundational evidence to support implementing a lay trauma training program in the United States, especially in remote areas [11].
We have taken our curriculum with previously shown success in rural India and implemented it in a one-day workshop with a varied group of students with myriad levels of medical knowledge and educational attainment. We hypothesized that the participants would attain or improve upon identified trauma ca-re skills in the given time, as measured by a written pre and posttest. It is our hope that by maximizing the efficacy of this program and widely distributing it amongst community stakeholders from a diverse set of backgrounds in West Texas, we can greatly impact the distribution of trauma first responders in this vast geographical area, and ultimately impact morbidity and mortality in trauma [12][13][14].

Materials and Methods
This prehospital training program has evolved over multiple trials to maximize clinical relevance and educational efficacy. The previous version of this course, which this pilot study's curriculum was based off of, was a ten-skill curriculum delivered in a one-day course in order to best replicate current trauma training curricula. This course was one day long and heavily emphasized skills most critically important to prehospital trauma care. This course was instructed by making broad use of presentations laden with images, complemented by a text manual that was comprehensive in nature, interactive sessions for skill practice and refinement, and debriefing in order to best support long term retention. Practical skills training incorporated a standard mannequin and basic first aid and trauma care tools.

Setting
The training program was conducted in the Texas Tech

University Health Sciences Center simulation center at Medical
Center Hospital in Odessa, Texas. The program was conducted over a full day in April 2016. This program was conducted as a pilot study to investigate the feasibility and efficacy of our international curriculum in a domestic but rural setting. We collaborated with community and institutional partners in hopes of conducting future training sessions in additional locations.

Participants
The individuals most likely to first interact with victims of trauma in West Texas include the police, firefighters, nurses, emergency medical technicians, and hospital staff. Participants from these fields were recruited with assistance from established stakeholders, which included a medical school dean and senior officials from local fire and police departments. Instructors were recruited from TTUHSC faculty and hospital staff [14][15][16][17][18]. The physicians trained were primarily comprised of family medicine residents-as they serve a major role as the first line in health care-and trauma care-in this region. Additionally, these residents and medical students were intended to serve as trainers to first responders and lay people in future events. A breakdown of the participants in this course can be seen in Figure 2.

Study Design
Our study aims to identify increases in confidence and competence of participants after completing our training curriculum. Improvement in confidence was measured using

Results
In the pre-course confidence assessment, Medical Students and   Through repeated study, we have identified weaknesses in the program that can be improved with continuing program evaluation and restructuring. A notable weakness in the ATT curriculum is the limited scope of topics taught relative to US-based trauma care curriculums (ATLS, BLS, etc) ( Table 1) & ( Figure 5). Topics in this curriculum were chosen based on feasibility of skill attainment and retention as well as potential clinical yield. Future program development will broaden skills taught at various tiers, as well as offering lower-tier training more frequently and in more locations.
Another structural weakness of this program is its' utilization of a 3-point Likert scale to represent confidence, as opposed to a 5or 7-point Likert scale to allow for better discrimination between differences in confidence. Table 1: Comparison of coverage and teaching efficacy of multiple skills between VGPEI, ATLS, ITLS and PHTLS. This chart shows that VGPEI is superior is having been studied and shown proven confidence improvement in multiple skill areas, as well as providing participants with a mock drill to practice their skills. O denotes the overall coverage of the subject material, Cf indicates confidence improvement, Cp indicates competence improvement, S denotes simulation teaching, M indicates a Mock Drill is performed with that skill and A denotes the use of animation-assisted education. NDA denotes that the topic either is not covered in the course or has not been studied. + Denotes the topic is mentioned and completion of the course indicates understanding of the concept. ++ denotes extensive coverage and mastery of the concept or skill. -indicates that the topic is not covered in the course. Indicates usage of a teaching modality or proven efficacy.

O Cf Cp S M A O Cf Cp S M A O Cf Cp S M A O Cf Cp S M A O Cf Cp S M A
Airway

Management of Unconscious
Patients  Table 2.