A survey of national physicians working in an active conflict zone: the challenges of emergency medical care in Iraq.

INTRODUCTION: There has been limited research on the perspectives and needs of national caregivers when confronted with large-scale societal violence. In Iraq, although the security situation has improved from its nadir in 2006-2007, intermittent bombings, and other hostilities continue. National workers remain the primary health resource for the affected populace. PROBLEM: To assess the status and challenges of national physicians working in the Emergency Departments of an active conflict area. METHODS: This study was a survey of civilian Iraqi doctors working in Emergency Departments (EDs) across Iraq, via a convenience sample of physicians taking the International Medical Corps (IMC) Doctor Course in Emergency Medicine, given in Baghdad from December 2008 through August 2009. RESULTS: The 148 physician respondents came from 11 provinces and over 50 hospitals in Iraq. They described cardiovascular disease, road traffic injuries, and blast and bullet injuries as the main causes of death and reasons for ED utilization. Eighty percent reported having been assaulted by a patient or their family member at least once within the last year; 38% reported they were threatened with a gun. Doctors reported seeing a median of 7.5 patients per hour, with only 19% indicating that their EDs had adequate physician staffing. Only 19% of respondents were aware of an established triage system for their hospital, and only a minority had taken courses covering ACLS- (16%) or ATLS-related (24%) material. Respondents reported a wide diversity of prior training, with only 3% having some type of specialized emergency medicine degree. CONCLUSIONS: The results of this study describe some of the challenges faced by national health workers providing emergency care to a violence-stricken populace. Study findings demonstrate high levels of violent behavior directed toward doctors in Iraqi Emergency Departments, as well as staffing shortages and a lack of formal training in emergency medical care.

Iraqi community members' knowledge, attitude and practice of emergency medical care: assessing civilian emergency medicine in an area of conflict.

The objective of this article is to assess community member knowledge, attitude, and practice of emergency medical care in Baghdad, Iraq. We performed a randomized, cluster-based, household Knowledge, Attitude, and Practice (KAP) survey regarding pre-hospital and hospital-based emergency medical care among Baghdad community members. A total of 1172 individuals participated in the survey. While most (93.5%) understood that for a serious injury, one should go to the hospital within three hours, only half (50.6%) felt that ambulances were beneficial and only 5% knew that there was a number to call in case of medical emergency. Regarding attitudes, only half (50.2%) of those interviewed felt an ambulance would arrive within an hour, while higher proportions of people believed that paramedics (59.1%) and medical staff working in emergency departments were adequately trained (71.5%). In terms of practice, most Iraqis responded that they would seek care in a hospital (84.8-90.0%) by means other than an ambulance (98.0-99.2%). However, if an ambulance arrived, 77% would allow it to transport their friends/family and 73.5% would trust the medical staff in the hospital to appropriately treat them. Our conclusion is that emergency medical care in Iraq is still in the development phase. Although numerous ambulances have been commissioned, scores of paramedics have been trained, and staff working in Baghdad Emergency Departments have undergone updates in their practice, the public does not appear to be fully informed of these changes. Future developments in Iraqi emergency medical care should include targeted efforts to expand the public awareness of such services.

Injury burden during an insurgency: the untold trauma of infrastructure breakdown in Baghdad, Iraq.

BACKGROUND: Injuries as a result of the ongoing violence in Iraq have been a topic of both lay and academic interest. However, to date, attempts to quantify injuries in the country have focused primarily on direct mortality, which represents only a small portion of overall injury burden and ignores those injuries indirectly resulting from the conflict-induced breakdown of Iraqi infrastructure. METHODS: We performed a cross-sectional household survey from October to November, 2009, within the Baghdad Governorate of central Iraq. Using two-stage cluster-sampling with a proportional-to-size methodology, we randomized a total of 60 clusters to Baghdad's five governmental districts. Within each cluster, we interviewed heads of households regarding all injuries during the last 3 months. RESULTS: We surveyed 1,172 households, gathering information regarding 7,396 individuals. Only 8.4% of injuries were intentional, and fatalities represented only a small fraction (1.7%) of overall injury burden. The well-publicized intentional explosions in Baghdad, although accounting for close to half (44%) of all intentional injuries, made up only 4% of the total. Other injuries at least partially attributable to the conflict-induced breakdown of Iraqi infrastructure proved a much larger burden, for example, those from electric shock, unintentional explosions, unintentional gunshot wounds, and falls. CONCLUSIONS: Past and current fighting in Baghdad continues to adversely affect the Iraqi populace, where the indirect effects of infrastructure breakdown are likely the primary source of injury. When measuring the burden of large-scale violence, health researchers should account for the full injury burden, including both injury morbidity and indirect injuries.