The 2019-2020 Novel Coronavirus (Severe Acute Respiratory Syndrome Coronavirus 2) Pandemic: A Joint American College of Academic International Medicine-World Academic Council of Emergency Medicine Multidisciplinary COVID-19 Working Group Consensus Paper.

What started as a cluster of patients with a mysterious respiratory illness in Wuhan, China, in December 2019, was later determined to be coronavirus disease 2019 (COVID-19). The pathogen severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel Betacoronavirus, was subsequently isolated as the causative agent. SARS-CoV-2 is transmitted by respiratory droplets and fomites and presents clinically with fever, fatigue, myalgias, conjunctivitis, anosmia, dysgeusia, sore throat, nasal congestion, cough, dyspnea, nausea, vomiting, and/or diarrhea. In most critical cases, symptoms can escalate into acute respiratory distress syndrome accompanied by a runaway inflammatory cytokine response and multiorgan failure. As of this article's publication date, COVID-19 has spread to approximately 200 countries and territories, with over 4.3 million infections and more than 290,000 deaths as it has escalated into a global pandemic. Public health concerns mount as the situation evolves with an increasing number of infection hotspots around the globe. New information about the virus is emerging just as rapidly. This has led to the prompt development of clinical patient risk stratification tools to aid in determining the need for testing, isolation, monitoring, ventilator support, and disposition. COVID-19 spread is rapid, including imported cases in travelers, cases among close contacts of known infected individuals, and community-acquired cases without a readily identifiable source of infection. Critical shortages of personal protective equipment and ventilators are compounding the stress on overburdened healthcare systems. The continued challenges of social distancing, containment, isolation, and surge capacity in already stressed hospitals, clinics, and emergency departments have led to a swell in technologically-assisted care delivery strategies, such as telemedicine and web-based triage. As the race to develop an effective vaccine intensifies, several clinical trials of antivirals and immune modulators are underway, though no reliable COVID-19-specific therapeutics (inclusive of some potentially effective single and multi-drug regimens) have been identified as of yet. With many nations and regions declaring a state of emergency, unprecedented quarantine, social distancing, and border closing efforts are underway. Implementation of social and physical isolation measures has caused sudden and profound economic hardship, with marked decreases in global trade and local small business activity alike, and full ramifications likely yet to be felt. Current state-of-science, mitigation strategies, possible therapies, ethical considerations for healthcare workers and policymakers, as well as lessons learned for this evolving global threat and the eventual return to a "new normal" are discussed in this article.

Assessment of Acute Obstetrical Needs and the Potential Utility of Point-Of-Care Ultrasound in the North East Region of Haiti: A Cross-Sectional Study.

Background: Point-of-care ultrasound (POCUS) implemented through task shifting to nontraditional users has potential as a diagnostic adjuvant to enhance acute obstetrical care in resource-constrained environments with limited access to physician providers. Objective: This study evaluated acute obstetrical needs and the potential role for POCUS programming in the North East region of Haiti. Methods: Data was collected on all women presenting to the obstetrical departments of two Ministry of Public Health and Population (MSPP)-affiliated public hospitals in the North East region of Haiti: Fort Liberté Hospital and Centre Medicosocial de Ouanaminthe. Data was obtained via retrospective review of hospital records from January 1 through March 31, 2016. Trained personnel gathered data on demographics, obstetrical history, diagnoses, clinical care and outcomes using a standardized tool. Diagnoses a priori, defined as those diagnoses whose detection could be assisted with POCUS, included multi-gestations, non-vertex presentation, cephalopelvic disproportion, placental abruption, placenta previa, spontaneous abortions, retained products and ectopic pregnancy. Results: Data were collected from 589 patients during the study period. Median maternal age was 26 years and median gestational age was 38 weeks. The most common reason for seeking care was pelvic pain (85.2%). Sixty-seven (11.5%) women were transferred to other facilities for higher-level care. Among cases not transferred, post-partum hemorrhage, infant mortality and maternal mortality occurred in 2.4%, 3.0% and 0.6% of cases, respectively. There were 69 cases with diagnoses that could have benefited from POCUS use. Between sites, significantly more cases had the potential for improved diagnostics with POCUS at Fort Liberté Hospital (19.8%) than Centre Medicosocial de Ouanaminthe (8.2%) (p < 0.001). Conclusion: Acute obstetrical care is common and POCUS has the potential to impact the care of obstetrical patients in the North East region of Haiti. Future programs evaluating the feasibility of task shifting and the sustainable impacts of acute obstetric POCUS in Haiti will be important.

Disaster Preparedness for Clinics - Further Study from Haiti.

OBJECTIVE: This team created a manual to train clinics in low- and middle-income countries (LMICs) to effectively respond to disasters. This study is a follow-up to a prior study evaluating disaster response. The team returned to previously trained clinics to evaluate retention and performance in a disaster simulation. BACKGROUND: Local clinics are the first stop for patients when disaster strikes LMICs. They are often under-resourced and under-prepared to respond to patient needs. Further effort is required to prepare these crucial institutions to respond effectively using the Incident Command System (ICS) framework. METHODS: Two clinics in the North East Region of Haiti were trained through a disaster manual created to help clinics in LMICs respond effectively to disasters. This study measured the clinic staff's response to a disaster drill using the ICS and compared the results to prior responses. RESULTS: Using the prior study's evaluation scale, clinics were evaluated on their ability to set up an ICS. During the mock disaster, staff was evaluated on a three-point scale in 13 different metrics, grading their ability to mitigate, prepare, respond, and recover in a disaster. By this scale, both clinics were effective (36/39; 92%) in responding to a disaster. CONCLUSION: The clinics retained much prior training, and after repeat training, the clinics improved their disaster response. Future study will evaluate the clinics' ability to integrate disaster response with country-wide health resources to enable an effective outcome for patients.

Human Trafficking in Areas of Conflict: Health Care Professionals' Duty to Act.

Given the significant global burden of human trafficking, the ability of clinicians to identify and provide treatment for trafficked persons is critical. Particularly in conflict settings, health care facilities often serve as the first and sometimes only point of contact for trafficked persons. As such, medical practitioners have a unique opportunity and an ethical imperative to intervene, even in nonclinical roles. With proper training, medical practitioners can assist trafficked persons by documenting human trafficking cases, thereby placing pressure on key stakeholders to enforce legal protections, and by providing adequate services to those trafficked.

A Comprehensive Framework for International Medical Programs: A 2017 consensus statement from the American College of Academic International Medicine.

The American College of Academic International Medicine (ACAIM) represents a group of clinicians who seek to promote clinical, educational, and scientific collaboration in the area of Academic International Medicine (AIM) to address health care disparities and improve patient care and outcomes globally. Significant health care delivery and quality gaps persist between high-income countries (HICs) and low-and-middle-income countries (LMICs). International Medical Programs (IMPs) are an important mechanism for addressing these inequalities. IMPs are international partnerships that primarily use education and training-based interventions to build sustainable clinical capacity. Within this overall context, a comprehensive framework for IMPs (CFIMPs) is needed to assist HICs and LMICs navigate the development of IMPs. The aim of this consensus statement is to highlight best practices and engage the global community in ACAIM's mission. Through this work, we highlight key aspects of IMPs including: (1) the structure; (2) core principles for successful and ethical development; (3) information technology; (4) medical education and training; (5) research and scientific investigation; and (6) program durability. The ultimate goal of current initiatives is to create a foundation upon which ACAIM and other organizations can begin to formalize a truly global network of clinical education/training and care delivery sites, with long-term sustainability as the primary pillar of international inter-institutional collaborations.

Development of a Global Health Milestones Tool for Learners in Emergency Medicine: A Pilot Project.

OBJECTIVES: In medical education and training, increasing numbers of institutions and learners are participating in global health experiences. Within the context of competency-based education and assessment methodologies, a standardized assessment tool may prove valuable to all of the aforementioned stakeholders. Milestones are now used as the standard for trainee assessment in graduate medical education. Thus, the development of a similar, milestone-based tool was undertaken, with learners in emergency medicine (EM) and global health in mind. METHODS: The Global Emergency Medicine Think Tank Education Working Group convened at the 2016 Society for Academic Medicine Annual Meeting in New Orleans, Louisiana. Using the Interprofessional Global Health Competencies published by the Consortium of Universities for Global Health's Education Committee as a foundation, the working group developed individual milestones based on the 11 stated domains. An iterative review process was implemented by teams focused on each domain to develop a final product. RESULTS: Milestones were developed in each of the 11 domains, with five competency levels for each domain. Specific learning resources were identified for each competency level and assessment methodologies were aligned with the milestones framework. The Global Health Milestones Tool for learners in EM is designed for continuous usage by learners and mentors across a career. CONCLUSIONS: This Global Health Milestones Tool for learners in EM may prove valuable to numerous stakeholders. The next steps include a formalized pilot program for testing the tool's validity and usability across training programs, as well as an assessment of perceived utility and applicability by collaborating colleagues working in training sites abroad.

Implementation of the World Health Organization Trauma Care Checklist Program in 11 Centers Across Multiple Economic Strata: Effect on Care Process Measures.

BACKGROUND: Trauma contributes more than ten percent of the global burden of disease. Initial assessment and resuscitation of trauma patients often requires rapid diagnosis and management of multiple concurrent complex conditions, and errors are common. We investigated whether implementing a trauma care checklist would improve care for injured patients in low-, middle-, and high-income countries. METHODS: From 2010 to 2012, the impact of the World Health Organization (WHO) Trauma Care Checklist program was assessed in 11 hospitals using a stepped wedge pre- and post-intervention comparison with randomly assigned intervention start dates. Study sites represented nine countries with diverse economic and geographic contexts. Primary end points were adherence to process of care measures; secondary data on morbidity and mortality were also collected. Multilevel logistic regression models examined differences in measures pre- versus post-intervention, accounting for patient age, gender, injury severity, and center-specific variability. RESULTS: Data were collected on 1641 patients before and 1781 after program implementation. Patient age (mean 34 ± 18 vs. 34 ± 18), sex (21 vs. 22 % female), and the proportion of patients with injury severity scores (ISS) ≥ 25 (10 vs. 10 %) were similar before and after checklist implementation (p > 0.05). Improvement was found for 18 of 19 process measures, including greater odds of having abdominal examination (OR 3.26), chest auscultation (OR 2.68), and distal pulse examination (OR 2.33) (all p < 0.05). These changes were robust to several sensitivity analyses. CONCLUSIONS: Implementation of the WHO Trauma Care Checklist was associated with substantial improvements in patient care process measures among a cohort of patients in diverse settings.

Epidemiology of Traumatic Injuries in the Northeast Region of Haiti: A Cross-sectional Study.

INTRODUCTION: More than 90% of traumatic morbidity and mortality occurs in low- and middle-income countries (LMIC). Haiti is the poorest country in the Western Hemisphere and lacks contemporary statistics on the epidemiology of traumatic injuries. This study aimed to characterize the burden of traumatic injuries among emergency department patients in the Northeast region of Haiti. METHODS: Data were collected from the emergency departments of all public hospitals in the Northeast region of Haiti, which included the Fort Liberté, Ouanaminthe, and Trou du Nord sites. All patients presenting for emergent care of traumatic injuries were included. Data were obtained via review of emergency department registries and patient records from October 1, 2013 through November 30, 2013. Data on demographics, mechanisms of trauma, and anatomical regions of injury were gathered using a standardized tool and analyzed using descriptive statistics. Temporal analysis of injury frequency was explored using regression modeling. RESULTS: Data from 383 patient encounters were accrued. Ouanaminthe Hospital treated the majority of emergent injuries (59.3%), followed by Fort Liberté (30.3%) and Trou du Nord (10.4%). The median age in years was 23 with 23.1% of patients being less than 15 years of age. Road traffic accidents (RTAs) and interpersonal violence accounted for 65.8% and 30.1% of all traumatic mechanisms, respectively. Extremity trauma was the most frequently observed anatomical region of injury (38.9%), followed by head and neck (30.3%) and facial (19.1%) injuries. Trauma due to RTA resulted in a single injury (83.8%) to either an extremity or the head and neck regions most frequently. A minority of patients had medical record documentation (37.9%). Blood pressure, respiratory rate, and mental status were documented in 19.3%, 4.1%, and 0.0% of records, respectively. There were 6.3 injuries/day during the data collection period with no correlation between the frequency of emergent trauma cases and day of the week (R(^2)=0.01). CONCLUSIONS: Traumatic injuries are a common emergent presentation in the Northeast region of Haiti with characteristics similar to other LMIC. Documentation and associated data to adequately characterize the burden of disease in this region are lacking. Road traffic accidents are the predominate mechanism of injury, suggesting that interventions addressing prevention and treatment of this common occurrence may provide public health benefits in this setting.

Emergency Care Capabilities in North East Haiti: A Cross-sectional Observational Study.

INTRODUCTION: The North East Department is a resource-limited region of Haiti. Health care is provided by hospitals and community clinics, with no formal Emergency Medical System and undefined emergency services. As a paucity of information exists on available emergency services in the North East Department of Haiti, the objective of this study was to assess systematically the existing emergency care resources in the region. METHODS: This cross-sectional observational study was carried out at all Ministry of Public Health and Population (MSPP)-affiliated hospitals in the North East Department and all clinics within the Fort Liberté district. A modified version of the World Health Organization (WHO) Tool for Situational Analysis to Assess Emergency and Essential Surgical Care and Generic Essential Emergency Equipment Lists were completed for each facility. RESULTS: Three MSPP hospitals and five clinics were assessed. Among hospitals, all had a designated emergency ward with 24 hour staffing by a medical doctor. All hospitals had electricity with backup generators and access to running water; however, none had potable water. All hospitals had x-ray and ultrasound capabilities. No computed tomography scanners existed in the region. Invasive airway equipment and associated medications were not present consistently in the hospitals' emergency care areas, but they were available in the operating rooms. Pulse oximetry was unavailable uniformly. One hospital had intermittently functioning defibrillation equipment, and two hospitals had epinephrine. Basic supplies for managing obstetrical and traumatic emergencies were available at all hospitals. Surgical services were accessible at two hospitals. No critical care services were available in the region. Clinics varied widely in terms of equipment availability. They uniformly had limited emergency medical equipment. The clinics also had inconsistent access to basic assessment tools (sphygmomanometers 20% and stethoscopes 60%). A protocol for transferring patients requiring a higher level of care was present in most (80%) clinics and one of the hospitals. However, no facility had a written protocol for transferring patients to other facilities. One hospital reported intermittent access to an ambulance for transfers. CONCLUSIONS: Deficits in the supply of emergency equipment and limited protocols for inter-facility transfers exist in North East Department of Haiti. These essential areas represent appropriate targets for interventions aimed at improving access to emergency care within the North East region of Haiti.

Mass-casualty Response to the Kiss Nightclub in Santa Maria, Brazil.

On January 27, 2013, a fire at the Kiss Nightclub in Santa Maria, Brazil led to a mass-casualty incident affecting hundreds of college students. A total of 234 people died on scene, 145 were hospitalized, and another 623 people received treatment throughout the first week following the incident.1 Eight of the hospitalized people later died.1 The Military Police were the first on scene, followed by the state fire department, and then the municipal Mobile Prehospital Assistance (SAMU) ambulances. The number of victims was not communicated clearly to the various units arriving on scene, leading to insufficient rescue personnel and equipment. Incident command was established on scene, but the rescuers and police were still unable to control the chaos of multiple bystanders attempting to assist in the rescue efforts. The Municipal Sports Center (CDM) was designated as the location for dead bodies, where victim identification and communication with families occurred, as well as forensic evaluation, which determined the primary cause of death to be asphyxia. A command center was established at the Hospital de Caridade Astrogildo de Azevedo (HCAA) in Santa Maria to direct where patients should be admitted, recruit staff, and procure additional supplies, as needed. The victims suffered primarily from smoke inhalation and many required endotracheal intubation and mechanical ventilation. There was a shortage of ventilators; therefore, some had to be borrowed from local hospitals, neighboring cities, and distant areas in the state. A total of 54 patients1 were transferred to hospitals in the capital city of Porto Alegre (Brazil). The main issues with the response to the fire were scene control and communication. Areas for improvement were identified, namely the establishment of a disaster-response plan, as well as regularly scheduled training in disaster preparedness/response. These activities are the first steps to improving mass-casualty responses.

Prehospital characteristics in the North East Department of Haiti: a cross-sectional study from a low-income setting without prehospital systems.

INTRODUCTION: Although prehospital care is recognized as key in health systems development, it has been largely neglected in Haiti. The North East Department is one of the poorest areas of Haiti, and is a region where no data on out-of-hospital health care exists. This research assessed prehospital characteristics in the North East Department with the aim of providing baseline data to inform prehospital systems development. METHODS: In this observational study, data were collected from patients presenting at the Fort Liberté Hospital, the public regional referral health center in the North East Department. Data were accrued from April 2, 2012 through June 5, 2012. All patients accessing acute care at the hospital were eligible for enrollment. After obtaining consent, data on demographics, health needs, and prehospital information were gathered via a standardized questionnaire administered by hospital staff trained in study protocols. RESULTS: Data were collected from 441 patient visits. The median age was 24 years, with 62% of the population being female. Medical complaints comprised 75% of visits, with fever and gastrointestinal complaints being the most common reasons for presentation. Traumatic injuries accounted for 25% of encounters, with an equal distribution of blunt and penetrating events. Extremity injuries were the most common traumatic subclassification. The majority of patients (67.2%) were transported by motorcycle taxi and paid transport fees. Trauma patients were more likely to be transported without charge (OR = 9.10; 95% CI, 2.19-37.76; P < .001). Medical patients were most commonly brought from home (78.5%) and trauma patients from a road/street setting (42.9%). Median time to presentation was 240 minutes (IQR = 120-500) and 65 minutes (IQR = 30-150) for medical and trauma complaints, respectively (P < .001). Eleven percent of patients reported receiving care prior to arrival. As compared with medical patients, trauma victims were less likely to have received prehospital care. CONCLUSIONS: Assessing prehospital care in this low-income setting that lacks surveillance systems was feasible and required minimal resources. Motorcycle taxi drivers function as the primary emergency transport mechanism and may represent an access point for prehospital interventions in the North East Department of Haiti. Out-of-hospital care is nearly nonexistent in the region and its development has the potential to yield public health benefits.

Emergency medicine systems advancement through community-based development.

Humanitarian health programs frequently focus on immediate relief and are supply side oriented or donor driven. More emphasis should be placed on long-term development projects that engage local community leaders to ensure sustainable change in health care systems. With the Emergency Medicine Educational Exchange (EMEDEX) International Rescue, Recover, Rebuild initiative in Northeast Haiti as a model, this paper discusses the opportunities and challenges in using community-based development to establish emergency medical systems in resource-limited settings.

Disasters and women's health: reflections from the 2010 earthquake in Haiti.

INTRODUCTION: Increasing attention is being focused on the needs of vulnerable populations during humanitarian emergency response. Vulnerable populations are those groups with increased susceptibility to poor health outcomes rendering them disproportionately affected by the event. This discussion focuses on women's health needs during the disaster relief effort after the 2010 earthquake in Haiti. REPORT: The Emergency Department (ED) of the temporary mobile encampment in L'Hôpital de l'Université d'Etat d'Haïti (HUEH) was the site of the team's disaster relief mission. In February 2010, most of the hospital was staffed by foreign physicians and nurses, with a high turnover rate. Although integration with local Haitian staff was encouraged, implementation of this practice was variable. Common presentations in the ED included infectious diseases, traumatic injuries, chronic disease exacerbations, and follow-up care of post-earthquake injuries and infections. Women-specific complaints included vaginal infections, breast pain or masses, and pregnancy-related concerns or complications. Women were also targets of gender-based violence. DISCUSSION: Recent disasters in Haiti, Pakistan, and elsewhere have challenged the international health community to provide gender-balanced health care in suboptimal environments. Much room for improvement remains. Although the assessment team was gender-balanced, improved incorporation of Haitian personnel may have enhanced patient trust, and improved cultural sensitivity and communication. Camp geography should foster both patient privacy and security during sensitive examinations. This could have been improved upon by geographically separating men's and women's treatment areas and using a barrier screen to generate a more private examination environment. Women's health supplies must include an appropriate exam table, emergency obstetrical and midwifery supplies, urine dipsticks, and sanitary and reproductive health supplies. A referral system must be established for patients requiring a higher level of care. Lastly, improved inter-organization communication and promotion of resource pooling may improve treatment access and quality for select gender-based interventions. CONCLUSION: Simple, inexpensive modifications to disaster relief health care settings can dramatically reduce barriers to care for vulnerable populations.

Effect of normal saline infusion on the diagnostic utility of base deficit in identifying major injury in trauma patients.

BACKGROUND: Base deficit (BD) is a reliable marker of metabolic acidosis and is useful in gauging hemorrhage after trauma. Resuscitation with chloride-rich solutions such as normal saline (NS) can cause a dilutional acidosis, possibly confounding the interpretation of BD. OBJECTIVES: To test the diagnostic utility of BD in distinguishing minor from major injury after administration of NS. METHODS: This was a prospective observational study at a Level 1 trauma center. The authors enrolled patients with significant mechanism of injury and measured BD at triage (BD-0) and at four hours after triage (BD-4). Major injury was defined by any of the following: injury severity score of > or =15, drop in hematocrit of > or = 10 points, or the patient requiring a blood transfusion. Patients were divided into a low-volume (NS < 2L) and a high-volume (NS 2L) group. Data were reported as mean (+/-SD). Student's t- and Wilcoxon tests were used to compare data. Receiver operating characteristic (ROC) curves tested the utility of BD-4 in differentiating minor from major injury in the study groups. RESULTS: Four hundred eighty-nine trauma patients (mean age, 36 [+/-18] yr) were enrolled; 82% were male, and 34% had penetrating injury. Major-(20%) compared with minor-(80%) injury patients were significantly (p = 0.0001) more acidotic (BD-0 mean difference: -3.3 mmol/L; 95% confidence interval [CI] = -2.5 to -4.2). The high-volume group (n = 174) received 3,342 (+/-1,821) mL, and the low-volume group (n = 315) received 621 (+/-509) mL of NS. Areas under the ROC curves for the high-volume (0.63; 95% CI = 0.52 to 0.74) and low-volume (0.73; 95% CI = 0.60 to 0.86) groups were not significantly different from each other. CONCLUSIONS: Base deficit was able to distinguish minor from major injury after four hours of resuscitation, irrespective of the volume of NS infused.