White Paper on Early Critical Care Services in Low Resource Settings.

This White Paper has been formally accepted for support by the International Federation for Emergency Medicine (IFEM) and by the World Federation of Intensive and Critical Care (WFICC), put forth by a multi-specialty group of intensivists and emergency medicine providers from low- and low-middle-income countries (LMICs) and high-income countries (HiCs) with the aim of 1) defining the current state of caring for the critically ill in low-resource settings (LRS) within LMICs and 2) highlighting policy options and recommendations for improving the system-level delivery of early critical care services in LRS. LMICs have a high burden of critical illness and worse patient outcomes than HICs, hence, the focus of this White Paper is on the care of critically ill patients in the early stages of presentation in LMIC settings. In such settings, the provision of early critical care is challenged by a fragmented health system, costs, a health care workforce with limited training, and competing healthcare priorities. Early critical care services are defined as the early interventions that support vital organ function during the initial care provided to the critically ill patient-these interventions can be performed at any point of patient contact and can be delivered across diverse settings in the healthcare system and do not necessitate specialty personnel. Currently, a single "best" care delivery model likely does not exist in LMICs given the heterogeneity in local context; therefore, objective comparisons of quality, efficiency, and cost-effectiveness between varying models are difficult to establish. While limited, there is data to suggest that caring for the critically ill may be cost effective in LMICs, contrary to a widely held belief. Drawing from locally available resources and context, strengthening early critical care services in LRS will require a multi-faceted approach, including three core pillars: education, research, and policy. Education initiatives for physicians, nurses, and allied health staff that focus on protocolized emergency response training can bridge the workforce gap in the short-term; however, each country's current human resources must be evaluated to decide on the duration of training, who should be trained, and using what curriculum. Understanding the burden of critical Illness, best practices for resuscitation, and appropriate quality metrics for different early critical care services implementation models in LMICs are reliant upon strengthening the regional research capacity, therefore, standard documentation systems should be implemented to allow for registry use and quality improvement. Policy efforts at a local, national and international level to strengthen early critical care services should focus on funding the building blocks of early critical care services systems and promoting the right to access early critical care regardless of the patient's geographic or financial barriers. Additionally, national and local policies describing ethical dilemmas involving the withdrawal of life-sustaining care should be developed with broad stakeholder representation based on local cultural beliefs as well as the optimization of limited resources.

Forearm ultrasound-guided nerve blocks vs landmark-based wrist blocks for hand anesthesia in healthy volunteers.

OBJECTIVE: Although ultrasound-guided regional nerve blocks have become more commonplace in the emergency department, there is no evidence to suggest that they are more effective than traditional landmark-based wrist blocks for hand anesthesia. We hypothesized that ultrasound-guided forearm nerve blocks would provide superior analgesia as compared with conventional landmark-based wrist blocks. METHODS: Eighteen paired nerve injections were performed by an experienced operator on 12 healthy volunteers. Each subject's right arm was assigned to receive either an ultrasound-guided forearm block with a saline placebo wrist block or a traditional landmark-based wrist block with a saline placebo ultrasound-guided forearm block. The subject's left arm then received the alternate approach. All blocks were performed with 3 mL of 1% lidocaine. We evaluated sensory block to pinprick. Secondary outcome variables included pain associated with injection, participant's subjective assessment of block effectiveness, and presence of any complications. RESULTS: At 15 minutes postinjection, 14 of 18 (78%; 95% confidence interval [CI], 59%-97%) ultrasound-guided forearm blocks were successful, as opposed to 10 of 18 (56%; 95% CI, 33%-79%) anatomic wrist blocks. The ultrasound-guided forearm blocks had a 22% (95% CI, 2%-42%; P=.032) higher rate of success than the wrist blocks. The ultrasound-guided forearm block was subjectively felt to be denser by 12 of 18 (67%) subjects (P=.0034)). CONCLUSIONS: Ultrasound-guided forearm nerve blocks performed by an experienced operator result in more effective hand anesthesia than traditional anatomic landmark-based wrist blocks.

Bedside ultrasound training at Muhimbili National Hospital in Dar es Salaam, Tanzania and Hospital San Carlos in Chiapas, Mexico.

INTRODUCTION: In resource-rich settings, bedside ultrasound has rapidly evolved to be a crucial part of emergency centre practice and a growing part of critical care practice. This portable and affordable technology may be even more valuable in resource-limited environments where other imaging modalities are inaccessible, but the optimal amount of training required to achieve competency in bedside ultrasound is largely unknown. We sought to evaluate the feasibility of implementation of a mixed-modality bedside ultrasound training course for emergency and generalist acute care physicians in limited resource settings, and to provide a description of our core course components, including specific performance goals, to facilitate implementation of similar initiatives. METHODS: We conducted a standardised training course at two distinct sites-one large, urban tertiary hospital in Tanzania with a dedicated Emergency Centre, and one small, rural, hospital in southern Mexico with a general, acute intake area. We report on pre-training ultrasound use at both sites, as well as pre- and post-training views on most useful indications. RESULTS: Overall, participants were very satisfied with the course, although approximately one-third of the providers at both sites would have preferred more hands-on training. All participants passed a standardised exam requiring image acquisition and interpretation. DISCUSSION: Introducing bedside ultrasound training in two distinct resource-limited settings was feasible and well-received. After a brief intensive period of training, participants successfully passed a comprehensive examination, including demonstration of standardised image acquisition and accurate interpretation of normal and abnormal studies.

INTRODUCTION: Dans les contextes riches en ressources, l'échographie au chevet du patient a rapidement évolué pour devenir un élément essentiel de la pratique en centre d'urgence et un élément d'importance croissante de la pratique des soins de courte durée. Cette technologie portable et abordable peut être encore plus précieuse dans des environnements limités en ressources où d'autres modes d'imagerie sont inaccessibles, mais la quantité optimale de formation nécessaire pour atteindre une compétence suffisante en échographie au chevet du patient est largement inconnue. Nous avons cherché à évaluer la faisabilité de la mise en œuvre d'un cours de formation en échographie au chevet du patient à modes mixtes pour les médecins de soins de courte durée d'urgence et généralistes dans un contexte aux ressources limitées, et à fournir une description des composantes de notre cours fondamental, notamment en termes d'objectifs de performance spécifiques, afin de faciliter la mise en œuvre d'initiatives similaires. MÉTHODES: Nous avons effectué un stage de formation normalisé sur deux sites distincts - un grand hôpital urbain tertiaire en Tanzanie équipé d'un Centre d'urgence dédié, et un petit hôpital rural au sud du Mexique ayant une zone d'admission de soins généraux intensifs. Nous établissons un rapport sur l'utilisation de l'échographie en pré-formation sur les deux sites, ainsi que sur les avis formulés avant et après la formation à propos des indications les plus utiles. RÉSULTATS: Dans l'ensemble, les participants étaient très satisfaits du cours, bien qu'environ un tiers des fournisseurs sur les deux sites auraient préféré plus de formation pratique. Tous les participants ont réussi un examen normalisé requérant une acquisition et une interprétation d'images. DISCUSSION: La fourniture d'une formation en échographie au chevet des patients dans deux contextes distincts aux ressources limitées était faisable et bien reçue. Après une brève période intensive de formation, les participants ont réussi un examen complet, incluant notamment la démonstration de l'acquisition d'image normalisée et de l'interprétation exacte d'études normales et anormale.

Comparison of the multiple mini-interview with the traditional interview for U.S. emergency medicine residency applicants: a single-institution experience.

PURPOSE: The multiple mini-interview (MMI) is a validated interview technique used primarily to evaluate medical school applicants. No study has compared MMIs with traditional interviews (TIs) in the evaluation of U.S. emergency medicine residency (EMR) applicants. METHOD: During the 2011-2012 interview season, a four-station MMI was incorporated into the interview process for EMR applicants at Alameda Health System-Highland Hospital (AHS). A postinterview anonymous questionnaire was offered to all applicants after they submitted their rank lists but prior to release of National Residency Matching Program results. Respondents rated their perceptions of the MMI and TI on a five-point Likert scale. McNemar chi-square test was used to explore differences in respondents' perceptions of interview styles. RESULTS: One hundred ten interviewees completed the survey (73%). Overall, applicants found the TI more enjoyable than the MMI process (98 [89%] compared with 48 [44%], McNemar chi-square=28.66, P<.01) and preferred the TI process to the MMI (66 [60%] compared with 9 [10%], McNemar chi-square=40.81, P<.01). Sixteen applicants (14%) indicated that the use of the MMI would negatively affect their ranking of the program. CONCLUSIONS: In contrast to prior studies, U.S. EMR applicants to AHS preferred the TI to the MMI. Further investigation into the use of the MMI for selecting U.S. EMR applicants is warranted.

Bedside ultrasonography for obstetric and gynecologic emergencies.

There has been an increase in the availability and use of bedside ultrasonography in the acute care setting. The approach to the female patient with a pelvic complaint (including pelvic pain, vaginal bleeding, vaginal bleeding in pregnancy, or vaginal discharge) has been transformed by the use of bedside ultrasonography. Providers familiar with the transabdominal and transvaginal (endocavitary) ultrasonographic examination can obtain more accurate information faster, thereby improving time to consultation or discharge and achieving an increase in patient satisfaction. This article reviews the use of ultrasonography for evaluation of obstetric and gynecologic complaints in the acute care setting.

A cluster of fulminant, fatal necrotizing community-associated methicillin-resistant Staphylococcus aureus pneumonias.

Community-associated methicillin-resistant Staphylococcus aureus is a frequent cause of skin and soft-tissue infections and is increasingly identified as a cause of pneumonia in immunocompetent patients. Panton-Valentine leukocidin, one of several leukocytotoxic peptides secreted by these cocci, is associated with increased virulence. A cluster of 3 unrelated patients with fatal pneumonia presumably caused by community-associated methicillin-resistant S aureus positive for Panton-Valentine leukocidin were treated in a 3-week period. Despite aggressive care and appropriate, timely administration of antibiotics, all 3 patients died. This article reviews the clinical and laboratory features suggestive of this lethal isolate, including unique findings on Gram stains of sputum.

Emergency department staff satisfaction with rapid human immunodeficiency virus testing.

OBJECTIVES: The authors sought to determine staff satisfaction with an emergency department (ED) rapid human immunodeficiency virus (HIV) testing program. METHODS: A survey was conducted in an urban ED that has provided rapid HIV testing (routine screening and physician-initiated testing) since August 2007. From May 1, 2008, to August 31, 2008, the survey was administered to all ED staff involved with HIV testing. The primary outcome was satisfaction, and secondary outcomes were the staff attitudes toward the program. RESULTS: Surveys were administered to 215 of the 217 staff members, and 207 surveys were returned (96% response rate); 201 surveys had complete data available for analysis. The response rate by staffing type was as follows: physicians 64/64 (100%), nurses 124/134 (93%), and registration staff 16/19 (84%). The majority of ED staff (99%; 95% confidence interval [CI] = 95% to 100%) were satisfied with the HIV testing program. Physicians, however, rated the program more favorably than nurses or registration staff. Most staff members agreed that HIV testing improved overall care (93%; 95% CI = 89% to 96%) and felt that HIV testing did not interfere with their ability to provide care (82%; 95% CI = 76% to 87%). The majority of staff perceived that patients were satisfied with the procedures for obtaining consent (73%; 95% CI = 67% to 79%) and with the way HIV testing was performed (83%; 95% CI = 77% to 87%). CONCLUSIONS: Emergency department staff satisfaction and overall attitudes with the HIV testing program is high. ED staff does not appear to be a barrier to program implementation.

Wenckebach Block due to Hyperkalemia: A Case Report.

Hyperkalemia is a commonly encountered electrolyte abnormality that can significantly alter normal cardiac conduction. Potentially lethal dysrhythmias associated with hyperkalemia include complete heart block and Mobitz Type II second-degree AV block. We report a unique case of Mobitz Type 1 second-degree atrioventricular (AV) block, known commonly as Wenckebach, due to hyperkalemia. The patient's symptoms and electrocardiogram (ECG) evidence of Wenckebach block resolved with lowering of serum potassium levels, with subsequent ECG showing first-degree AV block. This paper highlights an infrequently reported dysrhythmia associated with hyperkalemia that emergency physicians should be familiar with.

Tension pneumoperitoneum after intussusception pneumoreduction.

Intussusception is the most common cause of intestinal obstruction in infancy. Presentation, diagnostic workup, and treatment are well understood and noncontroversial. Complications of bowel perforation are also well documented. We discuss a case of tension pneumoperitoneum after intestinal perforation during intussusception pneumoreduction in a 5-month-old child and review initial presentation, diagnosis, and management of this disease. It is important to recognize this rare complication of pneumoreduction and promptly treat the ensuing tension pneumoperitoneum.