Non-Communicable Disease and the Need to Strengthen Prehospital Care: Experience from Kigali, Rwanda

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Many NCDs present as emergencies which require emergency response. We aimed to review NCDs transported by Service d’Aide Medicale Urgente (SAMU), the public ambulance service in Rwanda. Methods Descriptive analysis of a REDCap database was performed for medical cases between December 2012 to May 2016 and compared to non-medical cases. Student’s t-test, ANOVA, and chi square test were run with p < 0.05 considered significant. Results A total of 832 patients were seen. 51% were female, and the average age was 57 years old + 22. Cardiac indications were most common (52%) followed by diabetic complications (22%), cancer (16%) and stroke (10%). Patients with NCDs were more likely to be tachycardic, HR>100 bpm (OR 2.61 [P<0.001]), hypoxic with SPO2 <90% (OR 3.28 [P<0.0001]), hypotensive with blood pressure <100 mmHg (OR 2.65 [P20 breaths per minute (OR 2.06 [P<0.0001]). Conclusions Access to emergency services is essential for NCD management. Compared to other emergencies treated by SAMU in Kigali, Rwanda, the NCD cohort had a higher acuity despite being a smaller proportion. As NCDs increase, investment in robust prehospital care will have substantial value in LMICs. Health Economics & Outcomes Research Health Policy Non-communicable disease Rwanda Prehospital Low-and-Middle-Income-Country Africa Background Non-communicable diseases (NCDs) are the leading cause of death globally with 41 million deaths per year and rising. 1 All but one of the ten leading causes of death in high-income countries (HIC) are related to NCDs. 2 Cardiovascular diseases, cancers, respiratory diseases, and diabetes account for over 80% of premature NCD deaths, those aged 30 to 69 years of age, worldwide. 1 An epidemiological transition from communicable infectious diseases to NCDs is occurring in low-and middle-income countries (LMICs), as the incidence of NCDs in LMICs is rising. 3 Annually, 85% of all premature deaths in the world from NCDs occurred in LMICs. 1 By 2020, NCDs are estimated to contribute to 7 out of every 10 deaths in LMICs. 4 On the African continent, NCDs are estimated to become the most common cause of death by 2030. 5 This is leading to an impending crisis for many African LMICs which have made great strides in addressing communicable diseases but have not addressed NCDs. Specific to Rwanda, NCDs are an increasingly important cause of morbidity and mortality, accounting for an estimated 36% of all deaths annually. 6 As of 2013, NCDs accounted for at least 52% of district hospital outpatient consultations and 22% of district hospital admissions according to the Rwanda Health Management Information Systems. The probability of premature death from one of the four major NCDs (cardiovascular disease, diabetes, cancer, and chronic respiratory diseases) in Rwanda is 19%. 7 These NCDs result in life-threatening emergencies such as myocardial infarction, sepsis, coma, and seizures as well as significant morbidity, like limb amputation from delayed treatment. However, there is limited literature on management of NCD patients in the prehospital setting in Rwanda or in LMIC settings. Service d’Aide Medicale Urgente (SAMU) is Rwanda's only public emergency medical service and sees nearly 4,000 patients per year. 8 SAMU has used an electronic prehospital registry since 2013 to track prehospital care in Kigali. In this paper we aimed to describe the incidence of NCD patients managed by SAMU in Kigali, Rwanda. Methods Study Context and Setting Rwanda has a population of nearly 13 million people with 80% living in rural settings. 9 SAMU was established by the Rwandan Ministry of Health in 2007. It receives roughly 3,000 calls per month at the country’s only 912 emergency call center located in Kigali. 8 SAMU has its own fleet of 13 ambulances in Kigali, but works with 270 total ambulances located at district hospitals throughout the country to provide emergency and transfer care for the entire population. Data Collection and Patient Sample SAMU staff complete a ‘run sheet’ for every patient encounter consisting of patient information including age, gender, vitals, location of incident, as well as management on the field and during transport. Data from patient run sheets was manually transferred and stored using an electronic registry in REDCap (Vanderbilt University; Nashville, Tennessee, USA) created in collaboration with Brigham Women’s Hospital/Harvard Medical School, Virginia Commonwealth University (VCU), and SAMU. 8 For this study, we evaluated the registry for all available data since inception on all patients with NCDs treated by SAMU. We focused on complaints related to cardiovascular diseases, diabetes, cancer and stroke. This cohort was compared to all-cause emergency patients seen by SAMU. Variables The registry captures demographics, disease information, field vital signs, presentation, treatment, and transportation. Additionally, the SAMU dispatch team uses a triage system categorizing urgency for each case as “absolute,” “relative,” or “no urgency” based on mechanism, clinical presentation and vital signs. We further classified the data using vital signs to determine acuity of illness. Systolic blood pressure (BP) less than 100 mmHg was considered hypotensive and greater than 160 mmHg hypertensive. Blood glucose was less than 60 mg/dL or 3.3 mmol/L was considered hypoglycemic and greater than 300 mg/dL or 11.1 mmol/L as hyperglycemic. Heart rate (HR) greater than or equal to 100 beats per minute was considered tachycardia and oxygen saturation (SpO2) less than 90% as hypoxic. Tachypnea was a respiratory rate (RR) greater than or equal to 20. Shock index was calculated for all patients and defined as HR divided by systolic BP. Transport destinations used included referral hospitals (highest level of care), district hospitals (mid-level care), and health centers (primary care). Patients undergoing primary transportation were brought to their initial point of contact with the healthcare system while patients undergoing secondary transport were transferred between health facilities. Data Analysis The data was analyzed using descriptive statistics performed on SPSS version 25. Student’s t-test, ANOVA, and chi square test were run with p < 0.05 considered significant. Significant findings were further quantified by calculating odds ratios. The Proportional Mortality Ratio was determined and compared mortality due to NCDs with all-cause mortality of all patients in the SAMU registry. Only patients with recorded values for a given variable were included in analysis. Ethical Consideration The Ministry of Health of Rwanda and VCU approved the study plan. The approval included access to patients’ medical records. No informed consent was required. This project falls under a Memorandum of Understanding between the Ministry of Health of Rwanda and VCU to build trauma and emergency capacity in Rwanda. Results Demographics SAMU responded to a total of 11,161 patients between December 2012 and May 2016, of which 832 patients (7.5%) had at least one diagnosed NCD. The average age was mean 57 years old (standard deviation ± 22) years and the median was 60 years old (IQR: 60–75). The largest age group was > 70 years, accounting for 32% of the NCD population. This population was significantly older than the average age of SAMU patients that did not have an NCD, which was mean 30.5 years old ( ± standard deviation 14.5, p < 0.01). 52% of patients were female (Table 1 ). Table 1 Demographic information for patients with NCDs treated by SAMU Demographic N (%) Age in years (Average, SD) 57 ( ± 22) 0–4 14 (2) 5–14 11 (1.5) 15–29 74 (9) 30–49 168 (21) 50–59 128 (16) 60–69 148 (18.5) 70+ 260 (32) Gender Female 426 (52) Male 387 (48) Non-Communicable Diseases Diabetes and cardiac conditions composed the largest cohorts, representing 444 (53%) and 351 (42%) of all patients seen by SAMU over the study period respectively. Of the 444 patients presenting with diabetes, 96 (35%) were treated for hypoglycemia while 82 (30%) were treated for hyperglycemia. The most common cardiac complaint was hypertension (n = 187, 53%) followed by hypotension (n = 45, 13%) and chest pain (n = 30, 9%). There were 120 (1.0%) patients with cancer treated by SAMU. The most commonly identified cancer was prostate cancer (n = 21, 18%) followed by breast cancer (n = 16, 14%) and liver cancer (n = 15, 12.5%). A minority of patients were treated by SAMU for strokes (n = 67, 8%) (Table 2 ). Table 2 Non-communicable disease emergencies treated by SAMU Non-Communicable Disease N (%) Diabetes Mellitus 444 (53) Heart Disease 351 (42) Hypertension 187 (53) Hypotension 45 (13) Chest Pain 30 (4) Cardiac Decompensation 11 (1) Palpitations 9 (1) Shock 7 (0.8) Arrhythmia 5 (0.6) Myocardial Infarction 5 (0.6) Other 78 (9) Cancer 120 (14) Prostate 21 (3) Breast 16 (2) Liver 15 (2) Cervical 11 (1) Gastric 8 (1) Colon 7 (0.8) Lung 6 (0.7) Throat 3 (0.4) Skin 2 (0.2) Uterine 1 (0.1) Oral 1 (0.1) Other 33 (4) Stroke 67 (8) Presentation SAMU recorded vital signs upon arrival to the patient, and again depending on travel time to the hospital/health center. These findings, along with overall clinical presentation and stability, helped determine the urgency status of the patent. At the time of presentation there were 223 (28%) patients with tachypnea, 227 (28%) with tachycardia, 128 (16%) with SpO2 less than 90%, and 67 (9%) patients with hypotension. Abnormal vitals were significantly associated with NCDs compared to patients managed by SAMU without diagnosed NCDs (p < 0.001) (Table 3 ). Table 3 Presentation of patients upon arrival of SAMU Presentation NCDs Non-NCDs Odds [95% CI], p-value Hypotension 3.6 [2.7, 4.8], p < 0.001 < 90 67 (9) 202 (2) ≥ 90 734 (91) 7893 (98) Hypoxia 3.2 [2.6, 4.0], p < 0.001 < 90 128 (16) 460 (5) ≥ 90 693 (84) 7977 (95) Tachypnea 2.5 [2.1, 3.0], p 20 223 (28) 1112 (14) Tachycardia 2.4 [2.1, 2.9], p 100 227 (28) 1141 (1141) GCS ≤ 8 42 (5) 190 (2) 2.5 [1.8, 3.5], p < 0.001 9–12 165 (21) 446 (5) 13–14 123 (15) 545 (6) 15 472 (59) 7584 (87) Urgency No Urgency 44 (5) 1340 (13) Relative 545 (67) 7248 (72) Absolute 230 (28) 1534 (15) 2.2 [1.9, 2.6], p < 0.001 Death Yes 15 (2) 51 (1) 3.7 [2.1, 6.6], p < 0.001 No 738 (98) 9235 (99) Urgency status of each patient was determined by SAMU responders and classified as “Absolute,” “Relative,” or “No Urgency”. The majority of patients seen by SAMU were categorized as “Relative” (n = 545, 67%), but patients with NCDs had greater than 2 times the odds of being assigned an “Absolute” rating compared patients with no diagnosed NCDs (OR = 2.2 [CI 95% 1.9, 2.6], p < 0.01) (Table 3 ). Treatment and Transport Upon arriving at the scene, SAMU responders provided a number of interventions and made decisions regarding transportation. Many patients with NCDs underwent primary transportation from somewhere in the public to a health facility (n = 618, 75%). Most patients were transported within Kigali to the University Teaching Hospital - Kigali (CHUK) (n = 309, 40%) followed by Kibagabaga Hospital (n = 174, 22.5%) and King Faisal Hospital (n = 107, 14%). The average distance traveled by a patient was 19 Km ( ± 13.0) and ranged from 1 to 186 Km (IQR: 10–26). There were 49 (6%) patients who did not require transportation and 15 (2%) patients who died before SAMU arrived or before reaching a hospital (Table 4 ). The Proportional Mortality Ratio (PMR) of NCDs was 23% and patients with NCDs had greater than 3 times the odds of death compared to patients with no diagnosed NCDs (OR = 3.7 [CI 95% 2.1, 6.6], p < 0.01). Table 4 Transportation Data Primary Transportation 618 (75%) Secondary Transportation 208 (25%) Receiving Hospital 771 (92) CHUK 309 (40) Hospital Kibagabaga 174 (22.5) King Faisal Hospital 107 (14) Rwanda Military Hospital 57 (7) Other 124 (16) On Site Care Only 49 (6) Death 15 (2) Dead on arrival 6 (40) Died during transfer 9 (60) The most common interventions performed in the field by SAMU were the administration of fluids (NaCl 0.9% or Lactated Ringers) (n = 382, 46%) followed by oxygen therapy (n = 342, 41%). Over half had peripheral intravenous lines placed (n = 491, 59%). The medications used most frequently were diclofenac (n = 29, 3.5%) and paracetamol (n = 20, 2.5%) followed by diazepam (n = 16, 2%) and morphine (n = 16, 2%). A total of 67 (n = 67, 8%) patients received pain medications (Table 5 ). Table 5 Information regarding interventions and medications provided by SAMU upon arrival. Percentages based on total population of NCD patients (832). Interventions N (%) Peripheral IV 491 (59) Fluids (NaCl 0.9%, LR) 381 (46) Oxygen Therapy 342 (41) Dextrose 5% IV Infusion 150 (18) Cervical Collar 37 (4.5) Intubation 31 (4) Dextrose 50% IV Infusion 25 (3) Wound Dressing 13 (1.5) Immobilization 11 (1.5) Medications N (%) Diclofenac 29 (3.5) Paracetamol 20 (2.5) Diazepam 16 (2) Morphine 16 (2) Phenobarbital 12 (1.5) Adrenaline 11 (1.5) Pethidine 3 (0.5) Buscopan 3 (0.5) Ibuprofen 2 (0.2) Chlorpromazine 2 (0.2) Cimetidine 2 (0.2) Dexamethasone 2 (0.2) Ephedrine 2 (0.2) Salbutamol 2 (0.2) Thiopental Sodium 1 (0.1) Succinylcholine 1 (0.1) Aspirin 1 (0.1) Discussion This is one of the first studies to look at management of NCDs in an LMIC setting. In Kigali, Rwanda, the SAMU prehospital ambulance service routinely manages NCD-related cases, although at a smaller proportion than obstetric and traumatic cases. However, these NCD patients tended to be older and more critically ill and have higher odds of dying than the rest of SAMU patients based on Proportional Mortality Ratio. SAMU patients with NCDs had more vital sign derangements than other emergency patients. This may be because of delays in recognition of illness, delays in accessing care, and/or delays in availability of quality services. In obstetrics and gynecology, the three delay model describes delays: deciding to seek appropriate medical help for an obstetric emergency, reaching an appropriate obstetric facility, and receiving adequate care when a facility is reached. 10 This model can be translated to delays for NCDs. Patients in many LMICs experience delays in care-seeking generally due to sociocultural factors. 11,12 Lack of awareness of NCDs by the public or by medical staff, cultural practices contributing to delays in accessing care, cost of accessing care, shortages of staff or complexities of the current healthcare system may contribute to challenges for patients with NCDs. The general public may not be aware of the signs and symptoms of NCDs to seek help. The symptoms may be vague; for example, nausea and heartburn are known to be atypical symptoms of myocardial infarction in HIC settings. 13 The medical staff may not be familiar with signs and symptoms of acute NCDs since these are still fairly underrecognized. Lack of training and lack of nurses were previously described as barriers to adequate ICU care in LMICs. 14 Cultural practices may lead to delays in seeking care. Patients may seek care from traditional healers, for example. 15,16,17 These barriers to care have been noted across a variety of settings, in both HICs and LMICs. 18,19 The infrastructure of the health care system may also be a barrier. The referral system acts as a gatekeeping mechanism and may limit getting care for emergent conditions since patients need to progress to higher levels through the system. Furthermore, the healthcare system does not currently have advanced capabilities such as a cardiac catheterization lab, neurointerventional operating room, or cardiac surgical care currently -- which would be necessary to manage conditions such as myocardial infarction and stroke. These resources are being discussed at this time but would require time to deploy and only be available in Kigali. The AFRICARDIO2015 team has developed a consensus statement highlighting the need for equipping first line healthcare facilities with electrocardiograms, emergency rooms in large towns to have fibrinolytic therapy and large cities to have percutaneous cardiology intervention facilities. 20 These factors will need to be addressed to decrease the acuity of patients with NCDs and offer them the best chances for good outcomes in Rwanda. Prehospital care is one area of investment that may be low-hanging fruit since these staff can address all causes of emergencies, including NCDs. The Ministry of Health’s investment in SAMU since 2007 is noteworthy and likely to increase in necessity over time. SAMU patients with NCDs were much older than patients without NCDs. However, deaths between the ages of 30 and 69 years old are considered premature and therefore potentially preventable. Globally, 15 million deaths are attributed to NCDs in this age group. 1 SAMUs largest cohort of NCD patients was over 60 years old suggesting that the increase in life-expectancy over the last two decades in Rwanda may have resulted in a population that is aging and therefore at risk for developing NCDs. Another possible explanation may be that younger patients with NCDs may access care differently compared to this older cohort -- whether that means taking private transport to the hospital instead of calling the ambulance service or seeking care outside the country. Economy recovery in the last 25 years may have contributed to a well-to-do portion of the population that does not use the public emergency system. These are all areas that require further research in Rwanda. Lastly, public education on NCDs and their risk factors will be increasingly important as NCDs displace communicable diseases. In 2017, NCDs had the largest risk-attributable burden of any disease globally. 21 As primary health care in Rwanda improves, a health-literate population may be more likely to incorporate risk reduction strategies to decrease the incidence of NCDs. Risk factors of NCDs such as tobacco use, physical inactivity, excessive use of alcohol, and unhealthy diet are becoming more common as countries urbanize. 5,21 The Ministry of Health of Rwanda is working towards a national goal to reduce 80% of premature deaths caused by NCDs or by injury in people under 40 years of age by the year 2020 through two initiatives: car-free day and “80 × 40 × 20”. 22,23 Car-free day occurs twice a month, where parts of the city of Kigali close their roads and hold physical activities for the public to encourage a healthy lifestyle. 80 × 40 × 20 is These are valuable long-term strategies to decrease the incidence of NCDs and their attendant emergencies. Our study has several limitations. This study was limited to the prehospital setting. Patients were not followed through the emergency department or hospital stays because no infrastructure exists yet to connect data across these settings. This study, therefore, did not aim to study patient outcomes or whether patients received the correct treatment for their complaint. The data collection and entry process may have limitations from entry errors as well as omission and transcription errors. SAMU holds daily morning meetings to discuss patients seen during the last 24 hours which provides an internal check on the information logged into the run sheets, but no formal audit has been conducted of this data set. Finally, the patients with NCDs represented a small subset of the overall population therefore subgroup analyses are limited due to insufficient sample size to make valid statistical comparisons. Nevertheless, it is valuable to understand the care provided by SAMU for NCDs in Kigali using the best available data. Future directions may include creating data infrastructure to study patient outcomes and intervention studies to determine if prehospital interventions may reduce the mortality and morbidity from NCDs in LMIC settings. Conclusion This study shows that LMICs such as Rwanda must be more prepared for the rising tide of NCDs. LMIC health systems will need resources to manage these complicated and critically ill patients as NCDs become more prevalent. Prehospital services such as SAMU will have an essential role in stabilizing these critically ill patients and transporting them to appropriate centers that offer expert care. As the incidence of NCDs increases, investment into emergency departments, cardiac units, and critical care facilities will be vital to address the epidemiologic transition to NCDs. Abbreviations BP-Blood Pressure HIC- High-Income Country HR- Heart Rate LMIC- Low-and-Middle-Income-Country NCD- Non-communicable Disease RR- Respiratory Rate SAMU- Service d’Aide Medicale Urgente SPO2- Oxygen Saturation VCU- Virginia Commonwealth University Declarations Ethics Approval and Consent to Participate The Ministry of Health of Rwanda and VCU approved the study plan, IRB number HM20011011. The approval included access to patients’ medical records. No informed consent was required. This project falls under a Memorandum of Understanding between the Ministry of Health of Rwanda and VCU to build trauma and emergency capacity in Rwanda. Consent for Publication: All authors and institutions consent to the publication of this information. Competing Interests: None of the authors have any conflicts of interest. Funding: This work was supported by the National Institutes of Health R21:1R21TW010439-02, NIH P20: 1P20CA210284-01A, Rotary Foundation Global Grant #GG1749568. The grants supported a research fellow and faculty member to be in country to carry out the research and manuscript writing with the other authors in Rwanda. Authors Contributions: All authors have made substantial contributions to the design of the study, data analysis and interpretation, drafting the article, critical revisions or final approval of the version to be submitted. Acknowledgements: Pamela Walter, Thomas Jefferson University for her critical review of the manuscript. Availability of Data and Material: Data can be available upon reasonable request. References Non communicable diseases. https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases . Accessed 19 Nov 2019. WHO | The top 10 causes of death. (2017). https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death Accessed 19 Nov 2019. Islam, S. M. S. et al. Non-communicable diseases (NCDs) in developing countries: a symposium report. Global. Health . 2014; 10 :81. Diseases, on N. 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Delays in Breast Cancer Presentation and Diagnosis at Two Rural Cancer Referral Centers in Rwanda. Oncologist . 2015; 20 :780–788. Umuhoza, C., Karambizi, A. C., Tuyisenge, L. & Cartledge, P. Caregiver delay in seeking healthcare during the acute phase of pediatric illness, Kigali, Rwanda. Pan Afr. Med. J. 2018; 30 :160. Manzi, A. et al. Assessing predictors of delayed antenatal care visits in Rwanda: a secondary analysis of Rwanda demographic and health survey 2010. BMC Pregnancy Childbirth . 2014; 14 :290. Brinton, L. et al. Factors contributing to delays in diagnosis of breast cancers in Ghana, West Africa. Breast Cancer Res. Treat. 2017; 162 :105–114. Price, A. J., Ndom, P., Atenguena, E., Mambou Nouemssi, J. P. & Ryder, R. W. Cancer care challenges in developing countries. Cancer . 2012; 118 :3627–3635. Kakou-Guikahue, M. et al. Optimizing the management of acute coronary syndromes in sub-Saharan Africa: A statement from the AFRICARDIO 2015 Consensus Team. Arch. Cardiovasc. Dis. 2016; 109 :376–383. Stanaway, J. D. et al. Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet . 2018; 392 :1923–1994. Car-free day: What is the impact? The New Times | Rwanda https://www.newtimes.co.rw/lifestyle/car-free-day-what-impact (2018). Accessed 19 Nov 2019. Binagwaho, A., Muhimpundu, M. A., Bukhman, G. & NCD Synergies Group. 80 under 40 by 2020: an equity agenda for NCDs and injuries. Lancet . 2014; 383 :3–4. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Rosenberg","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0002-9249-4778","institution":"Virginia Commonwealth University Medical Center","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Ashley","middleName":"","lastName":"Rosenberg","suffix":""},{"id":378045,"identity":"5728308e-dff7-4095-9b14-6dbd3686244c","order_by":2,"name":"Jacqueline Mukagasasira","email":"","orcid":"","institution":"Republic of Rwanda Ministry of Health","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jacqueline","middleName":"","lastName":"Mukagasasira","suffix":""},{"id":378046,"identity":"de348e8b-03e2-4004-b530-3108b3580cd2","order_by":3,"name":"Verene Turikumana","email":"","orcid":"","institution":"Republic of Rwanda Ministry of Health","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Verene","middleName":"","lastName":"Turikumana","suffix":""},{"id":378047,"identity":"e3eceab4-a343-481b-aa2a-2a16dcfe2623","order_by":4,"name":"Myles Dworkin","email":"","orcid":"","institution":"Thomas Jefferson University Sidney Kimmel Medical College","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Myles","middleName":"","lastName":"Dworkin","suffix":""},{"id":378048,"identity":"c15c5b82-1b27-4f4a-a5cb-27f72dfdb692","order_by":5,"name":"Vizir Nsengimana","email":"","orcid":"","institution":"University of Rwanda","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Vizir","middleName":"","lastName":"Nsengimana","suffix":""},{"id":378049,"identity":"a6040796-ac20-455c-a868-f253b67e73d6","order_by":6,"name":"Pamela Bailey","email":"","orcid":"","institution":"Virginia Commonwealth University Medical Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Pamela","middleName":"","lastName":"Bailey","suffix":""},{"id":378050,"identity":"7b59f499-796e-4897-914f-5ade18166f93","order_by":7,"name":"Eugenie Kankindi","email":"","orcid":"","institution":"Republic of Rwanda Ministry of Health","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Eugenie","middleName":"","lastName":"Kankindi","suffix":""},{"id":378051,"identity":"57d411a7-a37c-4774-a056-9816f8e303ce","order_by":8,"name":"Mediatrice Niyonsaba","email":"","orcid":"","institution":"Republic of Rwanda Ministry of Health","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Mediatrice","middleName":"","lastName":"Niyonsaba","suffix":""},{"id":378052,"identity":"82c1907e-bea2-482d-8cfe-2c5aeb08a3d5","order_by":9,"name":"Menelas Nkeshimana","email":"","orcid":"","institution":"University of Rwanda College of Medicine and Health Sciences","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Menelas","middleName":"","lastName":"Nkeshimana","suffix":""},{"id":378053,"identity":"190d8b44-72f4-459f-8ad1-63f8d7415316","order_by":10,"name":"Jean Marie Uwitonze","email":"","orcid":"","institution":"Republic of Rwanda Ministry of Health","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jean","middleName":"Marie","lastName":"Uwitonze","suffix":""},{"id":378054,"identity":"9648fdf5-8377-418a-8a59-96401207d7e6","order_by":11,"name":"Igance Kabagema","email":"","orcid":"","institution":"Republic of Rwanda Ministry of Health","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Igance","middleName":"","lastName":"Kabagema","suffix":""},{"id":378055,"identity":"2b4bd13a-3579-44fe-901d-05347ce72b4f","order_by":12,"name":"Theophile Dushime","email":"","orcid":"","institution":"Republic of Rwanda Ministry of Health","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Theophile","middleName":"","lastName":"Dushime","suffix":""},{"id":378056,"identity":"f822ff40-017b-4012-818e-1a9bacf44fc6","order_by":13,"name":"Sudha Jayaraman","email":"","orcid":"","institution":"Virginia Commonwealth University Medical Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sudha","middleName":"","lastName":"Jayaraman","suffix":""}],"badges":[],"createdAt":"2020-02-27 15:11:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-15646/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-15646/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":13491698,"identity":"41e6ac92-3440-4b83-afcc-e5b624d124b1","added_by":"auto","created_at":"2021-09-16 22:28:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":322779,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-15646/v1/613e7fcd-23db-4065-b8a6-c894d7eda258.pdf"}],"financialInterests":"","formattedTitle":"Non-Communicable Disease and the Need to Strengthen Prehospital Care: Experience from Kigali, Rwanda","fulltext":[{"header":"Background","content":" \u003cp\u003eNon-communicable diseases (NCDs) are the leading cause of death globally with 41\u0026nbsp;million deaths per year and rising.\u003csup\u003e1\u003c/sup\u003e All but one of the ten leading causes of death in high-income countries (HIC) are related to NCDs.\u003csup\u003e2\u003c/sup\u003e Cardiovascular diseases, cancers, respiratory diseases, and diabetes account for over 80% of premature NCD deaths, those aged 30 to 69\u0026nbsp;years of age, worldwide.\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAn epidemiological transition from communicable infectious diseases to NCDs is occurring in low-and middle-income countries (LMICs), as the incidence of NCDs in LMICs is rising.\u003csup\u003e3\u003c/sup\u003e Annually, 85% of all premature deaths in the world from NCDs occurred in LMICs.\u003csup\u003e1\u003c/sup\u003e By 2020, NCDs are estimated to contribute to 7 out of every 10 deaths in LMICs.\u003csup\u003e4\u003c/sup\u003e On the African continent, NCDs are estimated to become the most common cause of death by 2030.\u003csup\u003e5\u003c/sup\u003e This is leading to an impending crisis for many African LMICs which have made great strides in addressing communicable diseases but have not addressed NCDs.\u003c/p\u003e \u003cp\u003eSpecific to Rwanda, NCDs are an increasingly important cause of morbidity and mortality, accounting for an estimated 36% of all deaths annually.\u003csup\u003e6\u003c/sup\u003e As of 2013, NCDs accounted for at least 52% of district hospital outpatient consultations and 22% of district hospital admissions according to the Rwanda Health Management Information Systems. The probability of premature death from one of the four major NCDs (cardiovascular disease, diabetes, cancer, and chronic respiratory diseases) in Rwanda is 19%.\u003csup\u003e7\u003c/sup\u003e These NCDs result in life-threatening emergencies such as myocardial infarction, sepsis, coma, and seizures as well as significant morbidity, like limb amputation from delayed treatment. However, there is limited literature on management of NCD patients in the prehospital setting in Rwanda or in LMIC settings.\u003c/p\u003e \u003cp\u003eService d\u0026rsquo;Aide Medicale Urgente (SAMU) is Rwanda's only public emergency medical service and sees nearly 4,000 patients per year.\u003csup\u003e8\u003c/sup\u003e SAMU has used an electronic prehospital registry since 2013 to track prehospital care in Kigali. In this paper we aimed to describe the incidence of NCD patients managed by SAMU in Kigali, Rwanda.\u003c/p\u003e "},{"header":"Methods","content":" \u003cp\u003e \u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eStudy Context and Setting\u003c/span\u003e \u003c/p\u003e \u003cp\u003eRwanda has a population of nearly 13\u0026nbsp;million people with 80% living in rural settings.\u003csup\u003e9\u003c/sup\u003e SAMU was established by the Rwandan Ministry of Health in 2007. It receives roughly 3,000 calls per month at the country\u0026rsquo;s only 912 emergency call center located in Kigali.\u003csup\u003e8\u003c/sup\u003e SAMU has its own fleet of 13 ambulances in Kigali, but works with 270 total ambulances located at district hospitals throughout the country to provide emergency and transfer care for the entire population.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eData Collection and Patient Sample\u003c/span\u003e \u003c/p\u003e \u003cp\u003eSAMU staff complete a \u0026lsquo;run sheet\u0026rsquo; for every patient encounter consisting of patient information including age, gender, vitals, location of incident, as well as management on the field and during transport. Data from patient run sheets was manually transferred and stored using an electronic registry in REDCap (Vanderbilt University; Nashville, Tennessee, USA) created in collaboration with Brigham Women\u0026rsquo;s Hospital/Harvard Medical School, Virginia Commonwealth University (VCU), and SAMU.\u003csup\u003e8\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFor this study, we evaluated the registry for all available data since inception on all patients with NCDs treated by SAMU. We focused on complaints related to cardiovascular diseases, diabetes, cancer and stroke. This cohort was compared to all-cause emergency patients seen by SAMU.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eVariables\u003c/span\u003e \u003c/p\u003e \u003cp\u003eThe registry captures demographics, disease information, field vital signs, presentation, treatment, and transportation. Additionally, the SAMU dispatch team uses a triage system categorizing urgency for each case as \u0026ldquo;absolute,\u0026rdquo; \u0026ldquo;relative,\u0026rdquo; or \u0026ldquo;no urgency\u0026rdquo; based on mechanism, clinical presentation and vital signs. We further classified the data using vital signs to determine acuity of illness. Systolic blood pressure (BP) less than 100\u0026nbsp;mmHg was considered hypotensive and greater than 160\u0026nbsp;mmHg hypertensive. Blood glucose was less than 60\u0026nbsp;mg/dL or 3.3\u0026nbsp;mmol/L was considered hypoglycemic and greater than 300\u0026nbsp;mg/dL or 11.1\u0026nbsp;mmol/L as hyperglycemic. Heart rate (HR) greater than or equal to 100 beats per minute was considered tachycardia and oxygen saturation (SpO2) less than 90% as hypoxic. Tachypnea was a respiratory rate (RR) greater than or equal to 20. Shock index was calculated for all patients and defined as HR divided by systolic BP. Transport destinations used included referral hospitals (highest level of care), district hospitals (mid-level care), and health centers (primary care). Patients undergoing primary transportation were brought to their initial point of contact with the healthcare system while patients undergoing secondary transport were transferred between health facilities.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003cp\u003eData Analysis\u003c/p\u003e \u003cp\u003eThe data was analyzed using descriptive statistics performed on SPSS version 25. Student\u0026rsquo;s t-test, ANOVA, and chi square test were run with p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 considered significant. Significant findings were further quantified by calculating odds ratios. The Proportional Mortality Ratio was determined and compared mortality due to NCDs with all-cause mortality of all patients in the SAMU registry. Only patients with recorded values for a given variable were included in analysis.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eEthical Consideration\u003c/span\u003e \u003c/p\u003e \u003cp\u003eThe Ministry of Health of Rwanda and VCU approved the study plan. The approval included access to patients\u0026rsquo; medical records. No informed consent was required. This project falls under a Memorandum of Understanding between the Ministry of Health of Rwanda and VCU to build trauma and emergency capacity in Rwanda.\u003c/p\u003e \u003c/div\u003e "},{"header":"Results","content":" \u003cp\u003e \u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eDemographics\u003c/span\u003e \u003c/p\u003e \u003cp\u003eSAMU responded to a total of 11,161 patients between December 2012 and May 2016, of which 832 patients (7.5%) had at least one diagnosed NCD. The average age was mean 57\u0026nbsp;years old (standard deviation\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;22) years and the median was 60\u0026nbsp;years old (IQR: 60\u0026ndash;75). The largest age group was \u0026gt;\u0026thinsp;70 years, accounting for 32% of the NCD population. This population was significantly older than the average age of SAMU patients that did not have an NCD, which was mean 30.5\u0026nbsp;years old (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;standard deviation 14.5, p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). 52% of patients were female (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003eDemographic information for patients with NCDs treated by SAMU\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eDemographic\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eN (%)\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAge in years (Average, SD)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e57 (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;22)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e0\u0026ndash;4\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e14 (2)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e5\u0026ndash;14\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e11 (1.5)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e15\u0026ndash;29\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e74 (9)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e30\u0026ndash;49\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e168 (21)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e50\u0026ndash;59\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e128 (16)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e60\u0026ndash;69\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e148 (18.5)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e70+\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e260 (32)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eGender\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eFemale\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e426 (52)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eMale\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e387 (48)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eNon-Communicable Diseases\u003c/span\u003e \u003c/p\u003e \u003cp\u003eDiabetes and cardiac conditions composed the largest cohorts, representing 444 (53%) and 351 (42%) of all patients seen by SAMU over the study period respectively. Of the 444 patients presenting with diabetes, 96 (35%) were treated for hypoglycemia while 82 (30%) were treated for hyperglycemia. The most common cardiac complaint was hypertension (n\u0026thinsp;=\u0026thinsp;187, 53%) followed by hypotension (n\u0026thinsp;=\u0026thinsp;45, 13%) and chest pain (n\u0026thinsp;=\u0026thinsp;30, 9%). There were 120 (1.0%) patients with cancer treated by SAMU. The most commonly identified cancer was prostate cancer (n\u0026thinsp;=\u0026thinsp;21, 18%) followed by breast cancer (n\u0026thinsp;=\u0026thinsp;16, 14%) and liver cancer (n\u0026thinsp;=\u0026thinsp;15, 12.5%). A minority of patients were treated by SAMU for strokes (n\u0026thinsp;=\u0026thinsp;67, 8%) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003eNon-communicable disease emergencies treated by SAMU\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eNon-Communicable Disease\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eN (%)\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eDiabetes Mellitus\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e444 (53)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eHeart Disease\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e351 (42)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eHypertension\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e187 (53)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eHypotension\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e45 (13)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eChest Pain\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e30 (4)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eCardiac Decompensation\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e11 (1)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ePalpitations\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e9 (1)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eShock\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e7 (0.8)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eArrhythmia\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e5 (0.6)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eMyocardial Infarction\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e5 (0.6)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eOther\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e78 (9)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eCancer\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e120 (14)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eProstate\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e21 (3)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eBreast\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e16 (2)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eLiver\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e15 (2)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eCervical\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e11 (1)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eGastric\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e8 (1)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eColon\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e7 (0.8)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eLung\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e6 (0.7)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eThroat\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e3 (0.4)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eSkin\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e2 (0.2)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eUterine\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1 (0.1)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eOral\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1 (0.1)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eOther\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e33 (4)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eStroke\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e67 (8)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003ePresentation\u003c/span\u003e \u003c/p\u003e \u003cp\u003eSAMU recorded vital signs upon arrival to the patient, and again depending on travel time to the hospital/health center. These findings, along with overall clinical presentation and stability, helped determine the urgency status of the patent. At the time of presentation there were 223 (28%) patients with tachypnea, 227 (28%) with tachycardia, 128 (16%) with SpO2 less than 90%, and 67 (9%) patients with hypotension. Abnormal vitals were significantly associated with NCDs compared to patients managed by SAMU without diagnosed NCDs (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003ePresentation of patients upon arrival of SAMU\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ePresentation\u003c/span\u003e\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eNCDs\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eNon-NCDs\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eOdds [95% CI], p-value\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eHypotension\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.6 [2.7, 4.8], p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u0026lt;\u0026thinsp;90\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e67 (9)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e202 (2)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;90\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e734 (91)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e7893 (98)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eHypoxia\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.2 [2.6, 4.0], p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u0026lt;\u0026thinsp;90\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e128 (16)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e460 (5)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;90\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e693 (84)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e7977 (95)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eTachypnea\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e2.5 [2.1, 3.0], p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026le;\u003c/span\u003e\u0026thinsp;20\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e568 (72)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e7112 (86)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u0026gt;\u0026thinsp;20\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e223 (28)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1112 (14)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eTachycardia\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e2.4 [2.1, 2.9], p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026le;\u003c/span\u003e\u0026thinsp;100\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e594 (72)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e7310 (86)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u0026gt;\u0026thinsp;100\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e227 (28)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1141 (1141)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eGCS\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026le;\u003c/span\u003e\u0026thinsp;8\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e42 (5)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e190 (2)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e2.5 [1.8, 3.5], p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e9\u0026ndash;12\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e165 (21)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e446 (5)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e13\u0026ndash;14\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e123 (15)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e545 (6)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e15\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e472 (59)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e7584 (87)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eUrgency\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eNo Urgency\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e44 (5)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1340 (13)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eRelative\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e545 (67)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e7248 (72)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAbsolute\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e230 (28)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e1534 (15)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e2.2 [1.9, 2.6], p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003e\u003cspan type=\"Bold\" class=\"Bold\" name=\"Emphasis\"\u003eDeath\u003c/span\u003e\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eYes\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e15 (2)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e51 (1)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cdiv class=\"SimplePara\"\u003e3.7 [2.1, 6.6], p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eNo\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e738 (98)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cdiv class=\"SimplePara\"\u003e9235 (99)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eUrgency status of each patient was determined by SAMU responders and classified as \u0026ldquo;Absolute,\u0026rdquo; \u0026ldquo;Relative,\u0026rdquo; or \u0026ldquo;No Urgency\u0026rdquo;. The majority of patients seen by SAMU were categorized as \u0026ldquo;Relative\u0026rdquo; (n\u0026thinsp;=\u0026thinsp;545, 67%), but patients with NCDs had greater than 2 times the odds of being assigned an \u0026ldquo;Absolute\u0026rdquo; rating compared patients with no diagnosed NCDs (OR\u0026thinsp;=\u0026thinsp;2.2 [CI 95% 1.9, 2.6], p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Italic\" class=\"Italic\" name=\"Emphasis\"\u003eTreatment and Transport\u003c/span\u003e \u003c/p\u003e \u003cp\u003eUpon arriving at the scene, SAMU responders provided a number of interventions and made decisions regarding transportation. Many patients with NCDs underwent primary transportation from somewhere in the public to a health facility (n\u0026thinsp;=\u0026thinsp;618, 75%). Most patients were transported within Kigali to the University Teaching Hospital - Kigali (CHUK) (n\u0026thinsp;=\u0026thinsp;309, 40%) followed by Kibagabaga Hospital (n\u0026thinsp;=\u0026thinsp;174, 22.5%) and King Faisal Hospital (n\u0026thinsp;=\u0026thinsp;107, 14%). The average distance traveled by a patient was 19\u0026nbsp;Km (\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026plusmn;\u003c/span\u003e\u0026thinsp;13.0) and ranged from 1 to 186\u0026nbsp;Km (IQR: 10\u0026ndash;26). There were 49 (6%) patients who did not require transportation and 15 (2%) patients who died before SAMU arrived or before reaching a hospital (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The Proportional Mortality Ratio (PMR) of NCDs was 23% and patients with NCDs had greater than 3 times the odds of death compared to patients with no diagnosed NCDs (OR\u0026thinsp;=\u0026thinsp;3.7 [CI 95% 2.1, 6.6], p\u0026thinsp;\u0026lt;\u0026thinsp;0.01).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003eTransportation Data\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ePrimary Transportation\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e618 (75%)\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eSecondary Transportation\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e208 (25%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eReceiving Hospital\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e771 (92)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eCHUK\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e309 (40)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eHospital Kibagabaga\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e174 (22.5)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eKing Faisal Hospital\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e107 (14)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eRwanda Military Hospital\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e57 (7)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eOther\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e124 (16)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eOn Site Care Only\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e49 (6)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eDeath\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e15 (2)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eDead on arrival\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e6 (40)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eDied during transfer\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e9 (60)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe most common interventions performed in the field by SAMU were the administration of fluids (NaCl 0.9% or Lactated Ringers) (n\u0026thinsp;=\u0026thinsp;382, 46%) followed by oxygen therapy (n\u0026thinsp;=\u0026thinsp;342, 41%). Over half had peripheral intravenous lines placed (n\u0026thinsp;=\u0026thinsp;491, 59%). The medications used most frequently were diclofenac (n\u0026thinsp;=\u0026thinsp;29, 3.5%) and paracetamol (n\u0026thinsp;=\u0026thinsp;20, 2.5%) followed by diazepam (n\u0026thinsp;=\u0026thinsp;16, 2%) and morphine (n\u0026thinsp;=\u0026thinsp;16, 2%). A total of 67 (n\u0026thinsp;=\u0026thinsp;67, 8%) patients received pain medications (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cdiv class=\"SimplePara\"\u003eInformation regarding interventions and medications provided by SAMU upon arrival. Percentages based on total population of NCD patients (832).\u003c/div\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eInterventions\u003c/div\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eN (%)\u003c/div\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ePeripheral IV\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e491 (59)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eFluids (NaCl 0.9%, LR)\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e381 (46)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eOxygen Therapy\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e342 (41)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eDextrose 5% IV Infusion\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e150 (18)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eCervical Collar\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e37 (4.5)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eIntubation\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e31 (4)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eDextrose 50% IV Infusion\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e25 (3)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eWound Dressing\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e13 (1.5)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eImmobilization\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e11 (1.5)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eMedications\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003eN (%)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eDiclofenac\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e29 (3.5)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eParacetamol\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e20 (2.5)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eDiazepam\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e16 (2)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eMorphine\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e16 (2)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ePhenobarbital\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e12 (1.5)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAdrenaline\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e11 (1.5)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003ePethidine\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e3 (0.5)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eBuscopan\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e3 (0.5)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eIbuprofen\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e2 (0.2)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eChlorpromazine\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e2 (0.2)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eCimetidine\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e2 (0.2)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eDexamethasone\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e2 (0.2)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eEphedrine\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e2 (0.2)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eSalbutamol\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e2 (0.2)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eThiopental Sodium\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1 (0.1)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eSuccinylcholine\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1 (0.1)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cdiv class=\"SimplePara\"\u003eAspirin\u003c/div\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cdiv class=\"SimplePara\"\u003e1 (0.1)\u003c/div\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e "},{"header":"Discussion","content":" \u003cp\u003eThis is one of the first studies to look at management of NCDs in an LMIC setting. In Kigali, Rwanda, the SAMU prehospital ambulance service routinely manages NCD-related cases, although at a smaller proportion than obstetric and traumatic cases. However, these NCD patients tended to be older and more critically ill and have higher odds of dying than the rest of SAMU patients based on Proportional Mortality Ratio.\u003c/p\u003e \u003cp\u003eSAMU patients with NCDs had more vital sign derangements than other emergency patients. This may be because of delays in recognition of illness, delays in accessing care, and/or delays in availability of quality services. In obstetrics and gynecology, the three delay model describes delays: deciding to seek appropriate medical help for an obstetric emergency, reaching an appropriate obstetric facility, and receiving adequate care when a facility is reached.\u003csup\u003e10\u003c/sup\u003e This model can be translated to delays for NCDs. Patients in many LMICs experience delays in care-seeking generally due to sociocultural factors.\u003csup\u003e11,12\u003c/sup\u003e Lack of awareness of NCDs by the public or by medical staff, cultural practices contributing to delays in accessing care, cost of accessing care, shortages of staff or complexities of the current healthcare system may contribute to challenges for patients with NCDs. The general public may not be aware of the signs and symptoms of NCDs to seek help. The symptoms may be vague; for example, nausea and heartburn are known to be atypical symptoms of myocardial infarction in HIC settings.\u003csup\u003e13\u003c/sup\u003e The medical staff may not be familiar with signs and symptoms of acute NCDs since these are still fairly underrecognized. Lack of training and lack of nurses were previously described as barriers to adequate ICU care in LMICs.\u003csup\u003e14\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eCultural practices may lead to delays in seeking care. Patients may seek care from traditional healers, for example.\u003csup\u003e15,16,17\u003c/sup\u003e These barriers to care have been noted across a variety of settings, in both HICs and LMICs.\u003csup\u003e18,19\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe infrastructure of the health care system may also be a barrier. The referral system acts as a gatekeeping mechanism and may limit getting care for emergent conditions since patients need to progress to higher levels through the system. Furthermore, the healthcare system does not currently have advanced capabilities such as a cardiac catheterization lab, neurointerventional operating room, or cardiac surgical care currently -- which would be necessary to manage conditions such as myocardial infarction and stroke. These resources are being discussed at this time but would require time to deploy and only be available in Kigali. The AFRICARDIO2015 team has developed a consensus statement highlighting the need for equipping first line healthcare facilities with electrocardiograms, emergency rooms in large towns to have fibrinolytic therapy and large cities to have percutaneous cardiology intervention facilities.\u003csup\u003e20\u003c/sup\u003e These factors will need to be addressed to decrease the acuity of patients with NCDs and offer them the best chances for good outcomes in Rwanda. Prehospital care is one area of investment that may be low-hanging fruit since these staff can address all causes of emergencies, including NCDs. The Ministry of Health\u0026rsquo;s investment in SAMU since 2007 is noteworthy and likely to increase in necessity over time.\u003c/p\u003e \u003cp\u003eSAMU patients with NCDs were much older than patients without NCDs. However, deaths between the ages of 30 and 69\u0026nbsp;years old are considered premature and therefore potentially preventable. Globally, 15\u0026nbsp;million deaths are attributed to NCDs in this age group.\u003csup\u003e1\u003c/sup\u003e SAMUs largest cohort of NCD patients was over 60\u0026nbsp;years old suggesting that the increase in life-expectancy over the last two decades in Rwanda may have resulted in a population that is aging and therefore at risk for developing NCDs. Another possible explanation may be that younger patients with NCDs may access care differently compared to this older cohort -- whether that means taking private transport to the hospital instead of calling the ambulance service or seeking care outside the country. Economy recovery in the last 25\u0026nbsp;years may have contributed to a well-to-do portion of the population that does not use the public emergency system. These are all areas that require further research in Rwanda.\u003c/p\u003e \u003cp\u003eLastly, public education on NCDs and their risk factors will be increasingly important as NCDs displace communicable diseases. In 2017, NCDs had the largest risk-attributable burden of any disease globally.\u003csup\u003e21\u003c/sup\u003e As primary health care in Rwanda improves, a health-literate population may be more likely to incorporate risk reduction strategies to decrease the incidence of NCDs. Risk factors of NCDs such as tobacco use, physical inactivity, excessive use of alcohol, and unhealthy diet are becoming more common as countries urbanize.\u003csup\u003e5,21\u003c/sup\u003e The Ministry of Health of Rwanda is working towards a national goal to reduce 80% of premature deaths caused by NCDs or by injury in people under 40\u0026nbsp;years of age by the year 2020 through two initiatives: car-free day and \u0026ldquo;80\u0026thinsp;\u0026times;\u0026thinsp;40\u0026thinsp;\u0026times;\u0026thinsp;20\u0026rdquo;.\u003csup\u003e22,23\u003c/sup\u003e Car-free day occurs twice a month, where parts of the city of Kigali close their roads and hold physical activities for the public to encourage a healthy lifestyle. 80\u0026thinsp;\u0026times;\u0026thinsp;40\u0026thinsp;\u0026times;\u0026thinsp;20 is These are valuable long-term strategies to decrease the incidence of NCDs and their attendant emergencies.\u003c/p\u003e \u003cp\u003eOur study has several limitations. This study was limited to the prehospital setting. Patients were not followed through the emergency department or hospital stays because no infrastructure exists yet to connect data across these settings. This study, therefore, did not aim to study patient outcomes or whether patients received the correct treatment for their complaint. The data collection and entry process may have limitations from entry errors as well as omission and transcription errors. SAMU holds daily morning meetings to discuss patients seen during the last 24 hours which provides an internal check on the information logged into the run sheets, but no formal audit has been conducted of this data set. Finally, the patients with NCDs represented a small subset of the overall population therefore subgroup analyses are limited due to insufficient sample size to make valid statistical comparisons. Nevertheless, it is valuable to understand the care provided by SAMU for NCDs in Kigali using the best available data. Future directions may include creating data infrastructure to study patient outcomes and intervention studies to determine if prehospital interventions may reduce the mortality and morbidity from NCDs in LMIC settings.\u003c/p\u003e "},{"header":"Conclusion","content":" \u003cp\u003eThis study shows that LMICs such as Rwanda must be more prepared for the rising tide of NCDs. LMIC health systems will need resources to manage these complicated and critically ill patients as NCDs become more prevalent. Prehospital services such as SAMU will have an essential role in stabilizing these critically ill patients and transporting them to appropriate centers that offer expert care. As the incidence of NCDs increases, investment into emergency departments, cardiac units, and critical care facilities will be vital to address the epidemiologic transition to NCDs.\u003c/p\u003e "},{"header":"Abbreviations ","content":"\u003cp\u003eBP-Blood Pressure\u003c/p\u003e\n\u003cp\u003eHIC- High-Income Country\u003c/p\u003e\n\u003cp\u003eHR- Heart Rate\u003c/p\u003e\n\u003cp\u003eLMIC- Low-and-Middle-Income-Country\u003c/p\u003e\n\u003cp\u003eNCD- Non-communicable Disease\u003c/p\u003e\n\u003cp\u003eRR- Respiratory Rate\u003c/p\u003e\n\u003cp\u003eSAMU- Service d\u0026rsquo;Aide Medicale Urgente\u003c/p\u003e\n\u003cp\u003eSPO2- Oxygen Saturation\u003c/p\u003e\n\u003cp\u003eVCU- Virginia Commonwealth University\u003c/p\u003e"},{"header":"Declarations ","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Ministry of Health of Rwanda and VCU approved the study plan, IRB number HM20011011. The approval included access to patients\u0026rsquo; medical records. No informed consent was required. This project falls under a Memorandum of Understanding between the Ministry of Health of Rwanda and VCU to build trauma and emergency capacity in Rwanda.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for Publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors and institutions consent to the publication of this information.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone of the authors have any conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the National Institutes of Health R21:1R21TW010439-02, NIH P20: 1P20CA210284-01A, Rotary Foundation Global Grant #GG1749568. The grants supported a research fellow and faculty member to be in country to carry out the research and manuscript writing with the other authors in Rwanda.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors Contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have made substantial contributions to the design of the study, data analysis and interpretation, drafting the article, critical revisions or final approval of the version to be submitted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePamela Walter, Thomas Jefferson University for her critical review of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Material:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData can be available upon reasonable request. \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References ","content":"\u003col\u003e\n\u003cli\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/Hpq3\"\u003eNon communicable diseases. \u003c/a\u003e\u003ca href=\"https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases\"\u003ehttps://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases\u003c/a\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/Hpq3\"\u003e.\u003c/a\u003e Accessed 19 Nov 2019.\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/dLTb\"\u003eWHO | The top 10 causes of death. (2017).\u003c/a\u003e \u003ca href=\"https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death\"\u003ehttps://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death\u003c/a\u003e Accessed 19 Nov 2019.\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/m0uh\"\u003eIslam, S. M. S. \u003c/a\u003e\u003cem\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/m0uh\"\u003eet al.\u003c/a\u003e\u003c/em\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/m0uh\"\u003e Non-communicable diseases (NCDs) in developing countries: a symposium report. \u003c/a\u003e\u003cem\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/m0uh\"\u003eGlobal. Health\u003c/a\u003e.\u003c/em\u003e 2014;\u003ca href=\"http://paperpile.com/b/iELBxV/m0uh\"\u003e10\u003c/a\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/m0uh\"\u003e:81.\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/ByDF\"\u003eDiseases, on N. GLOBAL STATUS REPORT.\u003c/a\u003e \u003ca href=\"https://www.who.int/nmh/publications/ncd_report2010/en/\"\u003ehttps://www.who.int/nmh/publications/ncd_report2010/en/\u003c/a\u003e Accessed 19 Nov 2019.\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/M0tt\"\u003eMaking some noise about noncommunicable diseases in Rwanda | | Blogs | CDC. \u003c/a\u003e\u003ca href=\"https://blogs.cdc.gov/global/2017/08/28/making-some-noise-rwanda/\"\u003ehttps://blogs.cdc.gov/global/2017/08/28/making-some-noise-rwanda/\u003c/a\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/M0tt\"\u003e.\u003c/a\u003e Accessed 19 Nov 2019.\u003c/li\u003e\n\u003cli\u003e\u003cem\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/HjRY\"\u003eNon Communicable Disease Policy\u003c/a\u003e\u003c/em\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/HjRY\"\u003e. \u003c/a\u003e\u003ca href=\"http://moh.gov.rw/fileadmin/templates/policies/NCDs_Policy.2015.pdf\"\u003ehttp://moh.gov.rw/fileadmin/templates/policies/NCDs_Policy.2015.pdf\u003c/a\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/HjRY\"\u003e (2015).\u003c/a\u003e Accessed 19 Nov 2019.\u003c/li\u003e\n\u003cli\u003e\u003cem\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/qSZ4\"\u003eNon Communicable Disease (NCD) Country Profiles: Rwanda\u003c/a\u003e\u003c/em\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/qSZ4\"\u003e. \u003c/a\u003e\u003ca href=\"https://www.who.int/nmh/countries/rwa_en.pdf\"\u003ehttps://www.who.int/nmh/countries/rwa_en.pdf\u003c/a\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/qSZ4\"\u003e (2018).\u003c/a\u003e Accessed 19 Nov 2019.\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/mxpf\"\u003eEnumah, S. \u003c/a\u003e\u003cem\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/mxpf\"\u003eet al.\u003c/a\u003e\u003c/em\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/mxpf\"\u003e Rwanda\u0026rsquo;s Model Prehospital Emergency Care Service: A Two-year Review of Patient Demographics and Injury Patterns in Kigali. \u003c/a\u003e\u003cem\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/mxpf\"\u003ePrehosp. Disaster Med.\u003c/a\u003e\u003c/em\u003e 2016;31:\u003ca href=\"http://paperpile.com/b/iELBxV/mxpf\"\u003e614\u0026ndash;620.\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/7vyv\"\u003eSize of the resident population | National Institute of Statistics Rwanda. \u003c/a\u003e\u003ca href=\"http://www.statistics.gov.rw/publication/size-resident-population\"\u003ehttp://www.statistics.gov.rw/publication/size-resident-population\u003c/a\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/7vyv\"\u003e.\u003c/a\u003e Accessed 19 Nov 2019.\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/ZWfl\"\u003eCombs Thorsen, V., Sundby, J. \u0026amp; Malata, A. 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Res.\u003c/a\u003e\u003c/em\u003e 2014;\u003ca href=\"http://paperpile.com/b/iELBxV/S72z\"\u003e14\u003c/a\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/S72z\"\u003e:528.\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/sfnI\"\u003eBrieger, D. \u003c/a\u003e\u003cem\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/sfnI\"\u003eet al.\u003c/a\u003e\u003c/em\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/sfnI\"\u003e Acute coronary syndromes without chest pain, an underdiagnosed and undertreated high-risk group: insights from the Global Registry of Acute Coronary Events. \u003c/a\u003e\u003cem\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/sfnI\"\u003eChest\u003c/a\u003e.\u003c/em\u003e 2004;\u003ca href=\"http://paperpile.com/b/iELBxV/sfnI\"\u003e126\u003c/a\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/sfnI\"\u003e:461\u0026ndash;469.\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/5mma\"\u003eHaniffa, R. \u003c/a\u003e\u003cem\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/5mma\"\u003eet al.\u003c/a\u003e\u003c/em\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/5mma\"\u003e Improving ICU services in resource-limited settings: Perceptions of ICU workers from low-middle-, and high-income countries. \u003c/a\u003e\u003cem\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/5mma\"\u003eJ. Crit. Care\u003c/a\u003e.\u003c/em\u003e 2018;\u003ca href=\"http://paperpile.com/b/iELBxV/5mma\"\u003e44\u003c/a\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/5mma\"\u003e:352\u0026ndash;356. \u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/lVHx\"\u003ePace, L. E. \u003c/a\u003e\u003cem\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/lVHx\"\u003eet al.\u003c/a\u003e\u003c/em\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/lVHx\"\u003e Delays in Breast Cancer Presentation and Diagnosis at Two Rural Cancer Referral Centers in Rwanda. \u003c/a\u003e\u003cem\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/lVHx\"\u003eOncologist\u003c/a\u003e.\u003c/em\u003e 2015;\u003ca href=\"http://paperpile.com/b/iELBxV/lVHx\"\u003e20\u003c/a\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/lVHx\"\u003e:780\u0026ndash;788.\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/jKnq\"\u003eUmuhoza, C., Karambizi, A. C., Tuyisenge, L. \u0026amp; Cartledge, P. Caregiver delay in seeking healthcare during the acute phase of pediatric illness, Kigali, Rwanda. \u003c/a\u003e\u003cem\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/jKnq\"\u003ePan Afr. Med. J.\u003c/a\u003e\u003c/em\u003e 2018;\u003ca href=\"http://paperpile.com/b/iELBxV/jKnq\"\u003e30\u003c/a\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/jKnq\"\u003e:160.\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/ATP3\"\u003eManzi, A. \u003c/a\u003e\u003cem\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/ATP3\"\u003eet al.\u003c/a\u003e\u003c/em\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/ATP3\"\u003e Assessing predictors of delayed antenatal care visits in Rwanda: a secondary analysis of Rwanda demographic and health survey 2010. \u003c/a\u003e\u003cem\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/ATP3\"\u003eBMC Pregnancy Childbirth\u003c/a\u003e.\u003c/em\u003e 2014;\u003ca href=\"http://paperpile.com/b/iELBxV/ATP3\"\u003e14\u003c/a\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/ATP3\"\u003e:290.\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/2pAS\"\u003eBrinton, L. \u003c/a\u003e\u003cem\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/2pAS\"\u003eet al.\u003c/a\u003e\u003c/em\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/2pAS\"\u003e Factors contributing to delays in diagnosis of breast cancers in Ghana, West Africa. \u003c/a\u003e\u003cem\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/2pAS\"\u003eBreast Cancer Res. Treat.\u003c/a\u003e\u003c/em\u003e 2017;\u003ca href=\"http://paperpile.com/b/iELBxV/2pAS\"\u003e162\u003c/a\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/2pAS\"\u003e:105\u0026ndash;114.\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/orbC\"\u003ePrice, A. J., Ndom, P., Atenguena, E., Mambou Nouemssi, J. P. \u0026amp; Ryder, R. W. Cancer care challenges in developing countries. \u003c/a\u003e\u003cem\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/orbC\"\u003eCancer\u003c/a\u003e.\u003c/em\u003e 2012;\u003ca href=\"http://paperpile.com/b/iELBxV/orbC\"\u003e118\u003c/a\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/orbC\"\u003e:3627\u0026ndash;3635.\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/e1UV\"\u003eKakou-Guikahue, M. \u003c/a\u003e\u003cem\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/e1UV\"\u003eet al.\u003c/a\u003e\u003c/em\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/e1UV\"\u003e Optimizing the management of acute coronary syndromes in sub-Saharan Africa: A statement from the AFRICARDIO 2015 Consensus Team. \u003c/a\u003e\u003cem\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/e1UV\"\u003eArch. Cardiovasc. Dis.\u003c/a\u003e\u003c/em\u003e 2016;\u003ca href=\"http://paperpile.com/b/iELBxV/e1UV\"\u003e109\u003c/a\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/e1UV\"\u003e:376\u0026ndash;383.\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/O3vz\"\u003eStanaway, J. D. \u003c/a\u003e\u003cem\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/O3vz\"\u003eet al.\u003c/a\u003e\u003c/em\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/O3vz\"\u003e Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990\u0026ndash;2017: a systematic analysis for the Global Burden of Disease Study 2017. \u003c/a\u003e\u003cem\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/O3vz\"\u003eLancet\u003c/a\u003e.\u003c/em\u003e 2018;\u003ca href=\"http://paperpile.com/b/iELBxV/O3vz\"\u003e392\u003c/a\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/O3vz\"\u003e:1923\u0026ndash;1994.\u003c/a\u003e\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/nA2N\"\u003eCar-free day: What is the impact? \u003c/a\u003e\u003cem\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/nA2N\"\u003eThe New Times | Rwanda\u003c/a\u003e\u003c/em\u003e \u003ca href=\"https://www.newtimes.co.rw/lifestyle/car-free-day-what-impact\"\u003ehttps://www.newtimes.co.rw/lifestyle/car-free-day-what-impact\u003c/a\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/nA2N\"\u003e (2018).\u003c/a\u003e Accessed 19 Nov 2019.\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/7aqc\"\u003eBinagwaho, A., Muhimpundu, M. A., Bukhman, G. \u0026amp; NCD Synergies Group. 80 under 40 by 2020: an equity agenda for NCDs and injuries. \u003c/a\u003e\u003cem\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/7aqc\"\u003eLancet\u003c/a\u003e.\u003c/em\u003e 2014;\u003ca href=\"http://paperpile.com/b/iELBxV/7aqc\"\u003e383\u003c/a\u003e\u003ca href=\"http://paperpile.com/b/iELBxV/7aqc\"\u003e:3\u0026ndash;4.\u003c/a\u003e\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Non-communicable disease, Rwanda, Prehospital, Low-and-Middle-Income-Country, Africa","lastPublishedDoi":"10.21203/rs.3.rs-15646/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-15646/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground Non-communicable diseases (NCDs) are increasing in incidence in low-and middle-income countries (LMICs). Many NCDs present as emergencies which require emergency response. We aimed to review NCDs transported by Service d’Aide Medicale Urgente (SAMU), the public ambulance service in Rwanda.\u003c/p\u003e\u003cp\u003eMethods Descriptive analysis of a REDCap database was performed for medical cases between December 2012 to May 2016 and compared to non-medical cases. Student’s t-test, ANOVA, and chi square test were run with p \u0026lt; 0.05 considered significant.\u003c/p\u003e\u003cp\u003eResults A total of 832 patients were seen. 51% were female, and the average age was 57 years old + 22. Cardiac indications were most common (52%) followed by diabetic complications (22%), cancer (16%) and stroke (10%). Patients with NCDs were more likely to be tachycardic, HR\u0026gt;100 bpm (OR 2.61 [P\u0026lt;0.001]), hypoxic with SPO2 \u0026lt;90% (OR 3.28 [P\u0026lt;0.0001]), hypotensive with blood pressure \u0026lt;100 mmHg (OR 2.65 [P\u0026lt;0.0001]), and tachypneic with respiratory rate \u0026gt;20 breaths per minute (OR 2.06 [P\u0026lt;0.0001]).\u003c/p\u003e\u003cp\u003eConclusions Access to emergency services is essential for NCD management. Compared to other emergencies treated by SAMU in Kigali, Rwanda, the NCD cohort had a higher acuity despite being a smaller proportion. As NCDs increase, investment in robust prehospital care will have substantial value in LMICs.\u003c/p\u003e","manuscriptTitle":"Non-Communicable Disease and the Need to Strengthen Prehospital Care: Experience from Kigali, Rwanda","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2020-03-02 19:20:16","doi":"10.21203/rs.3.rs-15646/v1","editorialEvents":[{"type":"communityComments","content":1}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c625d0c1-a7e2-40cb-aead-b64fe957c110","owner":[],"postedDate":"March 2nd, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":64585,"name":"Health Economics \u0026 Outcomes Research"},{"id":64586,"name":"Health Policy"}],"tags":[],"updatedAt":"2020-05-29T02:57:51+00:00","versionOfRecord":[],"versionCreatedAt":"2020-03-02 19:20:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-15646","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-15646","identity":"rs-15646","version":["v1"]},"buildId":"FbvkV6FR0MCFSLy54lSbu","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}