A Case for a Holistic Approach to the Improvement of Compliance among Hypertensive Patients: A Hospital Review.

The second Jamaica Health and Lifestyle Survey completed in 2007-2008 provided evidence that the prevalence of hypertension has increased significantly since 2000-2001. With more of the population living with hypertension, greater will be the need to ensure the best quality of life. A recent survey conducted in the ambulatory section of the Emergency Medicine Division at the University Hospital of the West Indies, identified a 36.5% non-compliance rate among the 52 patients prescribed with antihypertensive drugs. The reasons given for non-compliance with their antihypertensive medications are not new and included adverse effects, inconvenience and fear of dependence. However, in the same survey, it was also found that blood pressure was poorly controlled in 69.7% of the self-reported compliant subjects. Together, these points suggest that simply providing access to drugs is inadequate and a more holistic approach will be required to reduce blood pressure at the population level.

A clinical audit of the management of acute asthmatic attacks in adults and children presenting to an emergency department.

OBJECTIVE: To compare the guidelines in the University Hospital of the West Indies (UHWI) acute asthma management protocol with actual practice in the Accident and Emergency Department. METHODS: A prospective docket audit was done of all consecutive medical records of patients, presenting with a diagnosed acute asthmatic attack between June 1 and September 30, 2010, to the emergency department of the UHWI. A convenient sample was used. The audit tool used was created from the UHWI protocol for the emergency management of asthma in adults and children, as well as the British Adult Asthma Audit Tool. The audit tool assessed three main sections: initial assessment, initial management, and discharge considerations. Data were coded and entered in Microsoft Excel 2007 and statistical analyses conducted using Stata version 10. Management patterns were compared to the actual protocol and then discussed. RESULTS: A total of 15 864 patients were seen during the study period. Of these, a total of 293 patients were seen for a presentation of acute asthma. More females (57.3%) than males were seen, with the mean age of 33.53 years. Only 31% of patients were given a severity assessment of mild, moderate, or severe. Peak expiratory flow rate (PEFR) was attempted and recorded in 62%, but only 18.1% of patients had both pre and post PEFR done. Only 4.4% of patients were administered nebulizations within the suggested time frame. Positively, 94.2% of patients were given a prescription for inhaled corticosteroids and bronchodilators to continue post-discharge. CONCLUSIONS: Acute asthma management still remains an area of medical practice that continues to have long-standing difficulties. Failure to assess and document the severity of asthma attacks along with the under-utilization of PEFR was noted.

The compliance of healthcare workers with universal precautions in the emergency room at the university hospital of the west indies.

OBJECTIVES: The study assessed compliance among health workers in the Emergency Room at the University Hospital of the West Indies with universal precautions. This was done by determining the knowledge, practices and perceptions of staff of universal precautions and by assessing compliance. Reported adherence with universal precautions was compared with observed practice. METHODS: This was a cross-sectional study conducted over a one-year period. It was approved by the University Hospital of the West Indies/University of the West Indies/Faculty of Medical Sciences Ethics Committee. Data were analysed using Stata version 11.1. RESULTS: During the study period, 67 persons gave consent for the study, data were obtained for 62 of these participants and 52 of the respondents were observed. All of the participants were aware that universal precautions related to blood. Eighty-six per cent erroneously thought that universal precautions apply to urine. Seventy-nine per cent of the participants reported always washing their hands after performing a procedure and 43.5% reported always washing their hands before a procedure. Just over half of the participants reported always wearing gloves while doing procedures (56.5%). Only 9% reported always using a gown with a trauma patient. However, 31% and 43.3% reported wearing a gown when placing a chest tube and when anticipating splashes, respectively. Of those participants who reported washing their hands often after a procedure, over 30% did not perform hand-washing when observed. Fifty per cent of persons that reported never recapping needles were observed to recap needles by hand. CONCLUSION: The study revealed that compliance among staff in the Emergency Room with universal precautions was unsatisfactory. The need for education in this area was recognized.

A Survey of the Pain Management of Acute Painful Crisis among Patients with Sickle Cell Disease at Two Centres in Jamaica.

OBJECTIVES: The aim of this survey was to establish the pain management approaches to acute painful crisis (APC) in sickle cell patients at two healthcare facilities and to compare with available guidelines. METHODS: A multi-centre observational survey of the management of APC in sickle cell patients was conducted. Data were collected at the Sickle Cell Unit (SCU), Tropical Medicine Research Institute (TMRI) and Accident and Emergency Department (A&E), University Hospital of the West Indies. RESULTS: One hundred episodes of uncomplicated APC involving 81 patients managed at the SCU clinic and 64 episodes at the A&E in a total of 28 patients were included in the data set. Drugs used at the SCU included oral morphine, codeine and paracetamol and intramuscular diclofenac. At the A&E, parenteral morphine and pethidine were most commonly used. At the SCU, the mean time to initiation of analgesics was 38 minutes (IQR 25 to 50 minutes); at the A&E, this was 111 minutes (IQR 50 to 150 minutes). At the SCU, the mean duration of stay (DOS) was 2.9 hours (IQR 1.9 to 3.8 hours) with 94% of the patients being discharged home. At the A&E, the mean DOS was 13.0 hours (IQR 8.3 to 16.9 hours) with 93% of the patients being discharged home. The A&E patient group contained multiple high frequency presenters. Documentation of pain severity scores was inconsistent. CONCLUSION: The findings of the survey indicate that the management of APC at the two centres is substantially different. Further study is required to investigate patient satisfaction, centre preference and analgesic therapy efficacy.

Differences and similarities in explanatory models of hypertension in the United States of america, Tanzania and Jamaica.

BACKGROUND: Misperceptions detract from effective disease management in a number of conditions but the nature of underlying illness beliefs and their relative consistency in patients with chronic hypertension (cHTN) who present to the Emergency Department (ED) with poor blood pressure control is not known. OBJECTIVES: 1) To explore disease knowledge in ED patients with cHTN using explanatory modelling; and 2) to compare gaps in cHTN knowledge across racially similar but geographically divergent ED patients. METHODS: Emergency department patients of African origin with cHTN were recruited from three sites: Detroit Receiving Hospital (DRH - Detroit, MI), the Tanzanian Training Center for International Health (TTCIH - Ifakara, TZ) and the University Hospital of the West Indies (UHWI - Kingston, JA). Demographic and baseline data were collected along with open-ended responses to a series of questions related to cHTN. Qualitative responses were coded into predefined, disease-relevant quantitative domains by two separate, blinded reviewers and multilevel comparisons were performed using Kruskal-Wallis or analysis of variance (ANOVA) tests, where appropriate. RESULTS: One hundred and ninety-seven patients were enrolled; mean age (50.5 years vs 51.6 years vs 50.8 years; p = 0.86) and gender distribution (% male: 49.5 vs 44 vs 40; p = 0.53) were similar across sites but patients at DRH (vs TTCIH vs UHWI) were more hypertensive at presentation (mean systolic BP in mmHg: 166.8 vs 153 vs 152.7; p = 0.003), had a longer mean duration of cHTN (12.1 years vs 4.6 years vs 9.1; p < 0.0001), and were less likely to be on antihypertensive therapy (84.5% vs 92% vs 100%, p = 0.001). Explanatory models revealed limited recognition of cHTN as a "disease" (19.6% vs 28% vs 16%; p = 0.31) and consistency in the belief that cHTN was curable (44.3% vs 36% vs 42%; p = 0.62). Stress (48.4% vs 60% vs 50%; p = 0.31) and, especially at DRH, diet (62.2% vs 22% vs 36%; p < 0.0001) were identified most frequently as causes of cHTN and an association with symptoms was common (83.5% vs 98% vs 78%; p = 0.15). Clear differences existed for perceived benefits of treatment and consequences of poor control by site, but in general, both were under-appreciated. CONCLUSIONS: Misperceptions related to cHTN are common in ED patients. While specific areas of disconnect exist by geographic region, failure to recognize cHTN as a dire and fixed disease state is consistent, suggesting that a uniform educational intervention may be of benefit in this setting.

Health impact of research in emergency medicine--moving forward in the field.

This article provides a brief description of the conceptual framework of some specific areas of research carried out either collaboratively or independently in the Emergency Department in an effort to positively impact on health issues in an era of evidence-based medicine. The paper focusses on epidemiological studies of infectious diseases, chronic non-communicable diseases, and a recent update on trauma patterns. Conduction of clinical trials is also highlighted. The role of collaboration in Emergency medicine is also discussed. Research must be developed deliberately to facilitate the primary goal of improved patient care and outcomes. Further recommendations are suggested.

Role of routine chest radiographs in the evaluation of patients with stable blunt chest trauma--a prospective analysis.

OBJECTIVE: The study sought to assess the test performance characteristics of clinical judgement in the evaluation of stable blunt chest trauma patients compared with chest radiography (CXR) in the determination of significant intra-thoracic injury. METHODS: We prospectively enrolled all adult patients (older than 16years) who were considered to have stable blunt chest trauma over a six-month period (May 1-October 31, 2009). We defined the latter as patients who were unintubated, normotensive (systolic blood pressure > 90 mm Hg) and without hypoxia (oxygen saturation> 95% at room air). Patients eligible for the study were sent for anteroposterior (AP) CXRs which were then interpreted by the same consultant radiologist throughout the study period. Both test (clinical judgement) and disease status (CXR) were assigned and correlated as binary measures. We compared the test performance characteristics such as sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic likelihood ratios of clinical judgement to CXR findings in the determination of significant intra-thoracic injury. RESULTS: During the six-month period, data were collected from 77 eligible stable blunt chest trauma patients (age over 16 years). Fifty-nine patients (76.6%) were male. Nine patients (11.7%) were radiologically confirmed to have significant blunt chest injuries including rib fractures, pneumothorax and an isolated case of pulmonary contusion. All nine (11.7%) patients had a positive (abnormal) radiograph for rib fractures. In addition, three (3.9%) of them also had both rib fracture and pneumothoraces and one (1.3%) had both a rib fracture and pulmonary contusion. Clinical judgementfor the diagnosis of significant blunt chest injuries matched with the CXR finding with 95% confidence intervals (CIs): sensitivity 100% (95% CI 66.4, 100), specificity 32.4% (95% CI 21.5, 44.8), prevalence 11.7%, PPV 16.4% (95% CI 7.77, 28.8), NPV100% (95% CI 84.6, 100), DLR+ 1.48 (95% CI 1.25, 1.74). CONCLUSION: The majority ofpatients who sustained blunt chest injuries and were assessed as stable patients do not require CXR routinely. This study revealed that physicians in the local Emergency Department may be over-utilizing CXRfor patients who have stable blunt chest trauma.

Suicide attempt by self-poisoning: characteristics of suicide attempters seen at the Emergency Room at the University Hospital of the West Indies.

OBJECTIVE: To document the characteristics of self-poisoning suicide attempters who were brought to the University Hospital of the West Indies (UHWI) Emergency Room and to outline the type of drug used in the attempt. METHOD: This was a retrospective study conducted over the period 2005-2009. Data were gathered from patients' case records, log books and the hospital records using a questionnaire developed for this study. The questionnaire examined demographics, parameters of the drug ingested, patient's disposition, and reasons for attempt, final outcome and the type of discharge of patients who reported to the UHWI Emergency Room due to a suicide attempt by self-poisoning. RESULTS: Over the five-year period, 127 cases of suicide attempt by self-poisoning were reported. Significantly more females than males presented to the hospital due to self-poisoning (3:1, chi2 = 33.37; p < 0.001). Of this amount, 96 cases (75.6%) were females and 31 (24.4%) were males. The age group most recorded was 16-30 years (70.8%). The most common reason for the suicide attempt was an interpersonal conflict (52%). The drug category most often used in self-poisoning was analgesics (52%) with acetaminophens being the most common (26.2%). CONCLUSION: These findings are consistent with global suicide trends and indicate an urgent need to develop and implement national preventative and treatment measures for groups known to be at risk of suicidal attempts.

Hypoglycaemic complications with diabetes mellitus management: the predominant adverse drug reaction presenting to the Accident and Emergency Department of The University Hospital of the West Indies.

Evaluation of adverse drug reactions (ADRs) is important to the assessment of risk factors in an aim to ensure maximum benefits of drug therapy. This study was done to assess the types of ADRs presenting to the Accident and Emergency department (A&E) of the University Hospital of the West Indies. Admissions to the A&E associated with drugs were followed on a weekly basis for 19 weeks from October 2007 to February 2008 using the patient logbook. Medical records of patients with suspected ADRs were collected and evaluated by an Emergency Medicine Consultant of A & E to confirm the occurrence of ADRs and the suspected drug. Of the 8170 admissions to A&E, 48 (0.6%) were related to ADRs, with most occurring in females and the mean age (+/- standard error) was 58.9 (+/- 3.4) years. Drug induced hypoglycaemia accounted for 28 (56.3%) cases of ADRs and included mainly patients on insulin, with or without a sulphonylurea therapy. Most of these diabetic patients also had co-morbidities and were on multi-drug therapy (18). Allergic reactions accounted for 10 (21%) of the ADR outcomes. Other drugs accounting for ADRs included cardiovascular drugs (10.4%), analgesic/anti-inflammatory medications (8.3%), drugs acting on the central nervous system (8.3%) and anti-infectives (8.3%). It is concluded that drug-induced hypoglycaemia is the major ADR presenting to the A&E of the University Hospital of the West Indies; it is a preventable ADR and therefore further investigation should evaluate possible factors attributed to the occurrences.

Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2) A randomised, placebo-controlled trial.

BACKGROUND: Tranexamic acid can reduce bleeding in patients undergoing elective surgery. We assessed the effects of early administration of a short course of tranexamic acid on death, vascular occlusive events, and the receipt of blood transfusion in trauma patients. METHODS: This randomised controlled trial was undertaken in 274 hospitals in 40 countries. 20 211 adult trauma patients with, or at risk of significant bleeding were randomly assigned within 8 h of injury to either tranexamic acid (loading dose 1 g over 10 min then infusion of 1 g over 8 h) or matching placebo. Randomisation was balanced by centre, with an allocation sequence based on a block size of eight, generated with a computer random number generator Both participants and study staff (site investigators and trial coordinating centre staff) were masked to treatment allocation. The primary outcome was death in hospital within 4 weeks of injury, and was described with the following categories: bleeding, vascular occlusion (myocardial infarction, stroke and pulmonary embolism), multiorgan failure, head injury, and other AL analyses were by intention to treat. This study is registered as ISRCTN86750102, Clinicaltrials.gov NCT00375258, and South African Clinical Trial Register DOH-27-0607-1919. RESULTS: 10096 patients were allocated to tranexamic acid and 10 115 to placebo, of whom 10060 and 10067, respectively, were analysed. All-cause mortality was significantly reduced with tranexamic acid (1463 [14.5%] tranexamic acid group vs 1613 [160%] placebo group; relative risk 0.91, 95% CI 085-097; p = 00035). The risk of death due to bleeding was significantly reduced (489 [49%] vs 574 [5-7%]; relative risk 0-85, 95% CI 0.76-0.96; p = 0-0077). CONCLUSION: Tranexamic acid safely reduced the risk of death in bleeding trauma patients in this study On the basis of these results, tranexamic acid should be considered for use in bleeding trauma patients.

An assessment of clinical predictors of intracranial head injury identified by computed tomography scan.

A prospective study was done during a six-month period on 104 consecutive patients who were seen at the Accident and Emergency (A&E) Department of the UHWI and referred for CT scans of the head within 24 hours of sustaining head injuries. There were 74 (71.1%) males and 30 (28.8%) females. The mean age for females was 40.6 years and 32.4 years for males. Patients were clinically assessed for the presence or absence of vomiting, amnesia, loss of consciousness, bleeding of ear, nose and throat (ENT) and Glasgow Coma score (GCS). Negative predictive values were calculated for each parameter individually as well as the combination of all five. The absence of vomiting, amnesia, "loss of consciousness" (LOC) or ENT bleed had negative predictive values of 68%, 73%, 76% and 61.6% respectively. An assessment of Glasgow Coma Scale (GCS) of 15 had a 77.5% negative predictive value. When the history was indeterminate, the negative predictive values were 19%, 25%, 60% and 18% respectively for vomiting, amnesia, LOC and ENT bleed. When all four clinical indicators were absent in the history and examination and the GCS score 15, the negative predictive value for intracranial injury was 89.4%. In summary, the clinical indicators reviewed, alone or in combination, cannot exclude the presence of intracranial injury.

Delays in presentations of stroke patients at the University Hospital of the West Indies.

Thrombolytic therapy has been proven to be beneficial in selected patients with ischaemic strokes. Early diagnosis is paramount because there is a narrow therapeutic window for these patients to derive benefit from thrombolytics. We sought to evaluate the timing of stroke presentations at the University Hospital of the West Indies (UHWI) in order to assess the potential eligibility for definitive therapy A retrospective audit of all consecutive patients who had emergent computed tomographic (CT) scans for suspected ischaemic stroke at the UHWI was performed over a six-month period between February 2006 and July 2006. Data were extracted from the hospital records and analysed using SPSS version 12. There were 331 patients evaluated with brain CT for a clinically suspected stroke during the study period. Complete time documentation and CT scans were available for analysis in 171 patients with ischaemic strokes. The average age was 64.5 years (range +/- SD: 3-98 +/- 19.9 years) with a slight male preponderance (58% vs. 42%). There was considerable pre-hospital delay with 63% of patients presenting more than 12 hours after the onset of symptoms. There were also long inhospital delays. Only 52% of patients were assessed by a physician within an hour of presentation to hospital and only 55% of patients had CT scans completed within three hours of a physician s request. Although thrombolysis is not routinely performed for ischaemic strokes at our institution, sensitization of physicians and the general public in our setting to symptoms and signs of this disease is urgently needed to improve stroke management, whereby definitive treatment can be considered for selected patients.

Simultaneous spontaneous bilateral pneumothoraces in an asthmatic.

The occurrence of simultaneous spontaneous bilateral pneumothoraces is a very rare event. We present a case of a 14-year old asthmatic female patient who presented to the emergency room for routine treatment. While receiving nebulizations, she suddenly developed supraclavicular fullness with crepitus. Further examination revealed a clinical diagnosis of bilateral pneumothoraces. Although this phenomenon is more commonly associated with patients on mechanical ventilation, this case illustrates that physicians must be cognizant of this unique presentation in order to initiate early and aggressive lifesaving therapy. With rapid bilateral needle thoracocentesis followed by placement of bilateral thoracostomy tubes, the patient recovered well. In this report, we also attempt to briefly review the possible pathophysiology of this form of spontaneous pneumothorax.

The evolution of emergency medicine in Jamaica.

Emergency Medicine in Jamaica has evolved rapidly over the past 20 years and has gained recognition as a specialty. A residency training programme has been established, trademark life support courses are now available, moves to develop areas of sub-specialization have begun and an emergency medicine association has been formed. There has been an increase in the diagnostic modalities in the main teaching institution, the University Hospital of the West Indies (UHWI). There is an urgent need for improvements in pre-hospital care. This will require the development of an efficient Emergency Medical Service (EMS). More emphasis and attention is required on disaster medicine, toxicology and trauma. Increased training of emergency physicians and nurses, advances in academia and research, and greater advocacy by local emergency physicians will further advance the specialty.

Six years experience of angioedema at the University Hospital of the West Indies.

Angioedema (AE) is a problem that all doctors inclusive of emergency room physicians and the otolaryngologists are often asked to treat. We present a six-year experience with this disorder. In this series, angiotensin-converting enzyme inhibitors (ACEIs) were related to 60% of admissions for angioedema. Lip and tongue swelling was the most common manifestation. The discontinuation of ACEI therapy and supportive management are the recommended approaches to treatment and prevention of unfavourable outcomes. The authors strongly recommend medic alert bracelets for all patients with this disorder. The use and side effects of ACEI therapy in our population which is predominantly of African descent warrants further investigations.

Association between exposure/non-exposure to the mandatory seat belt law with regards to compliance in vehicle accident victims--a hospital review.

OBJECTIVE: Injuries sustained in motor vehicle accidents (MVAs) are a major challenge to the Jamaican healthcare system. In November 1999, Jamaica enacted legislation to make seat belt usage in motor vehicles compulsory. The effect of this policy change on seat belt usage is unclear. This study therefore sought to determine the prevalence of seat belt usage and to determine the association between exposure/non-exposure to the mandatory seat belt law and seat belt use in subjects who presented to the Accident and Emergency Department (A&E) of the University Hospital of the West Indies (UHWI) as a result of motor vehicle accidents. METHODS: Subjects were recruited from June to November 2003, post-seat belt law (POBL) period, and May to October 1999, pre-seat belt law (PRBL) period. Data collected included demographic variables, seat belt use and position of the occupants in the vehicle. RESULTS: Of the 277 patients who were eligible for inclusion, data were complete in 258 subjects, 87 in the PRBL period and 171 in the POBL period. The prevalence of seat belt use was 47% (PRBL) and 63% (POBL) respectively. There was no significant gender difference at each period. The odds of wearing seat belt in the rear of a motor vehicle were significantly lower than that of a driver (Table 3, OR 0.19, 95% CI 0.07, 0.48). Adjusting for age, gender and position in vehicle exposure, there was about 100% increase in the odds of seat belt use during the post seat belt law era (OR = 2.09, 95% CI 1.21, 3.61). CONCLUSION: It is concluded from this hospital-based study that the mandatory seat belt law legislature was associated with increased seat belt use in motor vehicle accident victims. However, current data from the Road Traffic Agency indicate that there is still an alarming number of fatalities. This clearly suggests that additional public health measures are needed to address the epidemic of motor vehicle trauma in Jamaica.

Penetrating neck trauma and the aberrant subclavian artery.

Vascular injuries from penetrating trauma to the base of the neck are accompanied by significant morbidity and potential mortality. These injuries require several diagnostic adjuncts in order to facilitate early diagnosis and appropriate treatment. Herein reported is the case of a patient who sustained penetrating injury to the thoracic inlet but had a fortuitous anomaly that prevented vascular injury and its attendant complications.