Derivation of the Difficult Airway Physiological Score (DAPS) in adults undergoing endotracheal intubation in the emergency department.

BACKGROUND: Prediction of serious outcomes among patients with physiological instability is crucial in airway management. In this study, we aim to develop a score to predict serious outcomes following intubation in critically ill adults with physiological instability by using clinical and laboratory parameters collected prior to intubation. METHOD: This single-center analytical cross-sectional study was conducted in the Emergency Department from 2016 to 2020. The airway score was derived using the transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) methodology. To gauge model's performance, the train-test split technique was utilized. The discrete random number generation approach was used to divide the dataset into two groups: development (training) and validation (testing). The validation dataset's instances were used to calculate the final score, and its validity was measured using ROC analysis and area under the curve (AUC). By computing the Youden's J statistic using the metrics sensitivity, specificity, positive predictive value, and negative predictive value, the discriminating factor of the additive score was determined. RESULTS: The mean age of the 1021 patients who needed endotracheal intubations was 52.2 years (± 17.5), and 632 (62%) of them were male. In the development dataset, there were 527 (64.9%) physiologically difficult airways, 298 (36.7%) post-intubation hypotension, 124 (12%) cardiac arrest, 347 (42.7%) shock index > 0.9, and 456 [56.2%] instances of pH < 7.3. On the contrary, in the validation dataset, there were 143 (68.4%) physiologically difficult airways, 33 (15.8%) post-intubation hypotension, 41 (19.6%) cardiac arrest, 87 (41.6%) shock index > 0.9, and 121 (57.9%) had pH < 7.3, respectively. There were 12 variables in the difficult airway physiological score (DAPS), and a DAPS of 9 had an area under the curve of 0.857. The accuracy of DAPS was 77%, the sensitivity was 74%, the specificity was 83.3%, and the positive predictive value was 91%. CONCLUSION: DAPS demonstrated strong discriminating ability for anticipating physiologically challenging airways. The proposed model may be helpful in the clinical setting for screening patients who are at high risk of deterioration.

Improvement in trauma care for road traffic injuries: an assessment of the effect on mortality in low-income and middle-income countries.

Over 90% of the annual 1·35 million worldwide deaths due to road traffic injuries (RTIs) occur in low-income and middle-income countries (LMICs). For this Series paper, our aim was two-fold. Firstly, to review evidence on effective interventions for victims of RTIs; and secondly, to estimate the potential number of lives saved by effective trauma care systems and clinical interventions in LMICs. We reviewed all the literature on trauma-related health systems and clinical interventions published during the past 20 years using MEDLINE, Embase, and Web of Science. We included studies in which mortality was the primary outcome and excluded studies in which trauma other than RTIs was the predominant injury. We used data from the Global Status Report on Road Safety 2018 and a Monte Carlo simulation technique to estimate the potential annual attributable number of lives saved in LMICs. Of the 1921 studies identified for our review of the literature, 62 (3·2%) met the inclusion criteria. Only 28 (1·5%) had data to calculate relative risk. We found that more than 200 000 lives per year can be saved globally with the implementation of a complete trauma system with 100% coverage in LMICs. Partial system improvements such as establishing trauma centres (>145 000 lives saved) and instituting and improving trauma teams (>115 000) were also effective. Emergency medical services had a wide range of effects on mortality, from increasing mortality to saving lives (>200 000 excess deaths to >200 000 lives saved per year). For clinical interventions, damage control resuscitation (>60 000 lives saved per year) and institution of interventional radiology (>50 000 lives saved per year) were the most effective interventions. On the basis of the scarce evidence available, a few key interventions have been identified to provide guidance to policy makers and clinicians on evidence-based interventions that can reduce deaths due to RTIs in LMICs. We also highlight important gaps in knowledge on the effects of other interventions.

Prevalence of neurological complaints among emergency department patients with severe hypertension.

OBJECTIVE: Severe hypertension can accompany neurological symptoms without obvious signs of target organ damage. However, acute cerebrovascular events can also be a cause and consequence of severe hypertension. We therefore use US population-level data to determine prevalence and clinical characteristics of patients with severe hypertension and neurological complaints. METHODS: We used nationally representative data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) collected in 2016-2019 to identify adult ED patients with severely elevated blood pressure (BP) defined as systolic BP ≥ 180 mmHg and/or diastolic BP ≥120 mmHg. We used ED reason for visit data fields to define neurological complaints and used diagnosis data fields to define acute target organ damage. We applied survey visit weights to obtain national estimates. RESULTS: Based on 5083 observations, an estimated 40.4 million patients (95% CI: 37.5-43.0 million) in EDs nationwide from 2016 to 2019 had severe hypertension, equating to 6.1% (95% CI: 5.7-6.5%) of all ED visits. Only 2.8% (95% CI: 2.0-3.9%) of ED patients with severe hypertension were diagnosed with acute cerebrovascular disease; hypertensive urgency was diagnosed in 92.0% (95% CI: 90.3-93.4%). Neurological complaints were frequent in both patients with (75.6%) and without (19.9%) cerebrovascular diagnoses. Hypertensive urgency patients with neurological complaints were more often older, female, had prior stroke/TIA, and had neuroimaging than patients without these complaints. Non-migraine headache and vertigo were the most common neurological complaints recorded. CONCLUSION: In a nationally representative survey, one-in-sixteen ED patients had severely elevated BP and one-fifth of those patients had neurological complaints.

Lifesaving skills training in schools - A qualitative study to explore students, teachers, and parent's perceived opportunities and challenges.

OBJECTIVE: The objective of this study is to explore the perception of teachers, parents and students' regarding implementation of a school-based lifesaving skills program and help predict potential barriers and solutions. METHODS: This qualitative exploratory study was conducted in Karachi, Pakistan, from December 2020- to October 2021. We included students, teachers, and parents of secondary (grades VIII, IX, and X) and higher secondary level students (grades XI and XII) in Karachi, Pakistan's public and private schools and colleges. We selected one public, two semi-private, and two private schools. We recruited students, teachers, and parents through convenience sampling. We conducted fifteen focus group discussions (FGDs) with the students, six FGDs with the teachers, and eighteen in-depth interviews (IDIs) with parents. We transcribed the data from audio recordings and translated it into the English language. Finally, we manually analyzed the data using thematic analyses. RESULTS: This study found that bystanders' main barriers to performing lifesaving skills are lack of knowledge, fear of legal involvement, fear of hurting the patient by incorrect technique, lack of empathy among community stakeholders, and gender bias. However, the participants had a positive and supportive attitude toward implementing lifesaving skills training in schools. They suggested starting student training in the early teenage years, preferred medical staff as trainers, and suggested frequent small sessions in English/Urdu both or Urdu language and training via theory and practical hands-on drills. Furthermore, the training was proposed to be integrated into the school curriculum to make it sustainable. Finally, the government needs to support the program and make the legal environment more conducive for bystanders. CONCLUSION: This study identified the significant barriers to performing lifesaving skills in an emergency in a low- and middle-income country (LMIC). The participants supported implementing a national lifesaving skills program in schools and colleges. However, the participants expressed that support is needed by the government for sustainability, integrating lifesaving skills into the school curriculum, providing legal support to the bystanders, and creating awareness among the general public.

Improvement in the diagnosis and practices of emergency healthcare providers for heat emergencies after HEAT (heat emergency awareness & treatment) an educational intervention: a multicenter quasi-experimental study.

BACKGROUND: The incidence of heat emergencies, including heat stroke and heat exhaustion, have increased recently due to climate change. This has affected global health and has become an issue of consideration for human health and well-being. Due to overlapping clinical manifestations with other diseases, and most of these emergencies occurring in an elderly patient, patients with a comorbid condition, or patients on poly medicine, diagnosing and managing them in the emergency department can be challenging. This study assessed whether an educational training on heat emergencies, defined as heat intervention in our study, could improve the diagnosis and management practices of ED healthcare providers in the ED setting. METHODS: A quasi-experimental study was conducted in the EDs of four hospitals in Karachi, Pakistan. Eight thousand two hundred three (8203) patients were enrolled at the ED triage based on symptoms of heat emergencies. The pre-intervention data were collected from May to July 2017, while the post-intervention data were collected from May to July 2018. The HEAT intervention, consisting of educational activities targeted toward ED healthcare providers, was implemented in April 2018. The outcomes assessed were improved recognition-measured by increased frequency of diagnosing heat emergencies and improved management-measured by increased temperature monitoring, external cooling measures, and intravenous fluids in the post-intervention period compared to pre-intervention. RESULTS: Four thousand one hundred eighty-two patients were enrolled in the pre-intervention period and 4022 in the post-intervention period, with at least one symptom falling under the criteria for diagnosis of a heat emergency. The diagnosis rate improved from 3% (n = 125/4181) to 7.5% (n = 7.5/4022) (p-value < 0.001), temperature monitoring improved from 0.9% (n = 41/4181) to 13% (n = 496/4022) (p-value < 0.001) and external cooling measure (water sponging) improved from 1.3% (n = 89/4181) to 3.4% (n = 210/4022) (p-value < 0.001) after the administration of the HEAT intervention. CONCLUSION: The HEAT intervention in our study improved ED healthcare providers' approach towards diagnosis and management practices of patients presenting with health emergencies (heat stroke or heat exhaustion) in the ED setting. The findings support the case of training ED healthcare providers to address emerging health issues due to rising temperatures/ climate change using standardized treatment algorithms.

Short-term stroke risk after emergency department treat-and-release headache visit.

OBJECTIVE: To evaluate whether patients discharged to home after an emergency department (ED) visit for headache face a heightened short-term risk of stroke. BACKGROUND: Stroke hospitalizations that occur soon after ED visits for headache complaints may reflect diagnostic error. METHODS: We conducted a retrospective cohort study using statewide administrative claims data for all ED visits and admissions at nonfederal hospitals in Florida 2005-2018 and New York 2005-2016. Using standard International Classification of Diseases (ICD) codes, we identified adult patients discharged to home from the ED (treat-and-release visit) with a benign headache diagnosis (cohort of interest) as well as those with a diagnosis of renal colic or back pain (negative controls). The primary study outcome was hospitalization within 30 days for stroke (ischemic or hemorrhagic) defined using validated ICD codes. We assess the relationship between index ED visit discharge diagnosis and stroke hospitalization adjusting for patient demographics and vascular comorbidities. RESULTS: We identified 1,502,831 patients with an ED treat-and-release headache visit; mean age was 41 (standard deviation: 17) years and 1,044,520 (70%) were female. A total of 2150 (0.14%) patients with headache were hospitalized for stroke within 30 days. In adjusted analysis, stroke risk was higher after headache compared to renal colic (hazard ratio [HR]: 2.69; 95% confidence interval [CI]: 2.29-3.16) or back pain (HR: 4.0; 95% CI: 3.74-4.3). In the subgroup of 26,714 (1.78%) patients with headache who received brain magnetic resonance imaging at index ED visit, stroke risk was only slightly elevated compared to renal colic (HR: 1.47; 95% CI: 1.22-1.78) or back pain (HR: 1.49; 95% CI: 1.24-1.80). CONCLUSION: Approximately 1 in 700 patients discharged to home from the ED with a headache diagnosis had a stroke in the following month. Stroke risk was three to four times higher after an ED visit for headache compared to renal colic or back pain.

Documenting response to COVID-individual and systems successes and challenges: a longitudinal qualitative study.

BACKGROUND: This study aimed to document the evolution of perceptions of frontline healthcare workers (FHCW) regarding their well-being and the quality of health systems' response to the COVID-19 pandemic over four months in Pakistan. METHODS: We conducted this prospective longitudinal qualitative study during the four months (June-September 2020) coinciding with the peak and trough of the first wave of Pakistan's COVID-19 pandemic. We approached frontline healthcare workers (physicians and nurses) working in emergency departments (ED) in two hospitals using the WhatsApp group of the Pakistan Society of Emergency Physicians (PSEM). Participants were asked to self-record their perception of their wellness and their level of satisfaction with the quality of their hospitals' response to the pandemic. We transcribed, translated, and analysed manually using MAXQDA 2020 software and conducted the thematic analysis to identify themes and sub-themes. RESULTS: We invited approximately 200 FHCWs associated with PSEM to participate in the study. Of the 61 who agreed to participate, 27 completed the study. A total of 149 audio recordings were received and transcribed. Three themes and eight sub-themes have emerged from the data. The themes were individual-level challenges, health system-level challenges, and hope for the future. Sub-themes for individual-level challenges were: fear of getting or transmitting infection, feeling demotivated and unappreciated, disappointment due to people's lack of compliance with COVID-19 protocols, physical exhaustion, and fatigue. For the healthcare system, sub-themes were: Infrastructure, logistics, management, and communications response of the hospital/healthcare system and financial stressors. For sub-themes under hope for the future were the improved disease knowledge and vaccine development. The overall perceptions and experiences of FHCWs evolved from fear, grief, and negativity to hope and positivity as the curve of COVID-19 went down. CONCLUSION: This study shows that the individuals and systems were not prepared to deal with the challenges of the COVID-19 pandemic. The findings highlight the challenges faced by individuals and health systems during the wake of the Covid-19 pandemic. The healthcare workers were emotionally and physically taxed, while the health systems were overwhelmed by COVID-19. The overall perceptions of FHCWs evolved with time and became negative to positive as the curve of COVID-19 went down during the first wave of COVID-19 in Pakistan.

Out of hospital cardiac arrest: experience of a bystander CPR training program in Karachi, Pakistan.

BACKGROUND: Nearly 90% of out-of-hospital cardiac arrest (OHCA) patients are witnessed, yet only 2.3% received bystander cardiopulmonary resuscitation (CPR) in Pakistan. This study aimed to determine retention of knowledge and skills of Hands-Only CPR among community participants in early recognition of OHCA and initiation of CPR in Karachi, Pakistan. METHODS: Pre and post-tests were conducted among CPR training participants from diverse non-health-related backgrounds from July 2018 to October 2019. Participants were tested for knowledge and skills of CPR before training (pre-test), immediately after training (post-test), and 6 months after training (re-test). All the participants received CPR training through video and scenario-based demonstration using manikins. Post-training CPR skills of the participants were assessed using a pre-defined performance checklist. The facilitator read out numerous case scenarios to the participants, such as drowning, poisoning, and road traffic injuries, etc., and then asked them to perform the critical steps of CPR identified in the scenario on manikins. The primary outcome was the mean difference in the knowledge score and skills of the participants related to the recognition of OHCA and initiation of CPR. RESULTS: The pre and post-tests were completed by 652 participants, whereas the retention test after 6 months was completed by 322 participants. The mean knowledge score related to the recognition of OHCA, and initiation of CPR improved significantly (p < 0.001) from pre-test [47.8/100, Standard Deviation (SD) ±13.4] to post-test (70.2/100, SD ±12.1). Mean CPR knowledge after 6 months (retention) reduced slightly from (70.2/100, ±12.1) to (66.5/100, ±10.8). CPR skill retention for various components (check for scene safety, check for response, check for breathing and correct placement of the heel of hands) deteriorated significantly (p < 0.001) from 77.9% in the post-test to 72.8% in re-test. Participants performed slightly better on achieving an adequate rate of chest compressions from 73.1% in post-test to 76.7% in re-test (p 0.27). CONCLUSION: Community members with non-health backgrounds can learn and retain CPR skills, allowing them to be effective bystander CPR providers in OHCA situations. We recommend mass population training in Pakistan for CPR to increase survival from OHCA.

Acceptability of telephone-cardiopulmonary resuscitation (T-CPR) practice in a resource-limited country- a cross-sectional study.

BACKGROUND: T-CPR has been shown to increase bystander CPR rates dramatically and is associated with improved patient survival. OBJECTIVE: To evaluate the acceptability of T-CPR by the bystanders and identify baseline quality measures of T-CPR in Karachi, Pakistan. METHODS: A cross-sectional study was conducted from January to December 2018 at the Aman foundation command and control center. Data was collected from audiotaped phone calls of patients who required assistance from the Aman ambulance and on whom the EMS telecommunicator recognized the need for CPR and provided instructions. Information was recorded using a structured questionnaire on demographics, the status of the patient, and different time variables involved in CPR performance. A One-way ANOVA was used to compare different time variables with recommended AHA guidelines. P-value ≤ 0.05 was considered significant. RESULTS: There were 481 audiotaped calls in which CPR instruction was given, listened to, and recorded data. Out of which in 459(95.4%) of cases CPR was attempted Majority of the patients were males (n = 278; 57.8%) and most had witnessed cardiac arrest (n = 470; 97.7%) at home (n = 430; 89.3%). The mean time to recognize the need for CPR by an EMS telecommunicator was 4:59 ± 1:59(min), while the mean time to start CPR instruction by a bystander was 5:28 ± 2:24(min). The mean time to start chest compression was 6:04 ± 1:52(min.). CONCLUSION: Our results show the high acceptability of T-CPR by bystanders. We also found considerable delays in recognizing cardiac arrest and initiation of CPR by telecommunicators. Further training of telecommunicators could reduce these delays.

Perception of the healthcare professionals towards the current trauma and emergency care system in Kabul, Afghanistan: a mixed method study.

BACKGROUND: Trauma and injury contribute to 11% of the all-cause mortality in Afghanistan. The study aimed to explore the perceptions of the healthcare providers (pre and in-hospital), hospital managers and policy makers of the public and private health sectors to identify the challenges in the provision of an effective trauma care in Kabul, Afghanistan. METHODS: A concurrent mixed method design was used, including key-informant interviews (healthcare providers, hospital managers and policy makers) of the trauma care system (N = 18) and simultaneous structured emergency care system assessment questionnaire (N = 35) from July 15 to September 25, 2019. Interviews were analyzed using content analysis approach and structured questionnaire data were descriptively analyzed. RESULTS: Four themes were identified that describe the challenges: 1) pre-hospital care, 2) cohesive trauma management system, 3) physical and human resources and 4) stewardship. Some key challenges were found related to scene and transportation care, in-hospital care and emergency preparedness within the wider trauma care system. Less than 25% of the population is covered by the pre-hospital ambulance system (n = 23, 65.7%) and there is no communication process between health care facilities to facilitate transfer (n = 28, 80%). Less than 25% of patients with an injury requiring emergent surgery have access to surgical care in a staffed operating theatre within 2 h of injury (n = 19, 54.2%) and there is no regular assessment of the ability of the emergency care system to mobilize resources (human and physical) to respond to disasters, and other large-scale emergencies (n = 28, 80%). CONCLUSION: This study highlighted major challenges in the delivery of trauma care services across Kabul, Afghanistan. Systematic improvement in the workforce training, structural organization of the trauma care system and implementing externally validated clinical guidelines for trauma management could possibly enhance the functions of the existing trauma care services. However, an integrated state-run trauma care system will address the current burden of traumatic injury more effectively within the wider healthcare system of Afghanistan.

Telemedicine in the United States: An Introduction for Students and Residents.

Telemedicine refers to the delivery of medical care and provision of general health services from a distance. Telemedicine has been practiced for decades with increasing evidence proving its potential for enhanced quality of care for patients, reduction in hospital readmissions, and increase in savings for both patients and providers. The COVID-19 pandemic has resulted in a significant increase in the reliance on telemedicine and telehealth for provision of health care services. Developments in telemedicine should be structured as complements to current health care procedures, not with the goal of completely digitizing the entire health care system, but rather to use the power of technology to enhance areas that may not be working at their full potential. At the same time, it is also clear that further research is needed on the effectiveness of telemedicine in terms of both financial and patient benefits. We discuss the current and rapidly increasing knowledge about the use of telemedicine in the United States, and identify the gaps in knowledge and opportunities for further research. Beginning with telemedicine's origins in the United States to its widespread use during the COVID-19 pandemic, we highlight recent developments in legislation, accessibility, and acceptance of telemedicine.

Identifying barriers for out of hospital emergency care in low and low-middle income countries: a systematic review.

BACKGROUND: Out-of-hospital emergency care (OHEC), also known as prehospital care, has been shown to reduce morbidity and mortality from serious illness. We sought to summarize literature for low and low-middle income countries to identify barriers to and key interventions for OHEC delivery. METHODS: We performed a systematic review of the peer reviewed literature from January 2005 to March 2015 in PubMed, Embase, Cochrane, and Web of Science. All articles referencing research from low and low-middle income countries addressing OHEC, emergency medical services, or transport/transfer of patients were included. We identified themes in the literature to form six categories of OHEC barriers. Data were collected using an electronic form and results were aggregated to produce a descriptive summary. RESULTS: A total 1927 titles were identified, 31 of which met inclusion criteria. Barriers to OHEC were divided into six categories that included: culture/community, infrastructure, communication/coordination, transport, equipment and personnel. Lack of transportation was a common problem, with 55% (17/31) of articles reporting this as a hindrance to OHEC. Ambulances were the most commonly mentioned (71%, 22/31) mode of transporting patients. However, many patients still relied on alternative means of transportation such as hired cars, and animal drawn carts. Sixty-one percent (19/31) of articles identified a lack of skilled personnel as a key barrier, with 32% (10/31) of OHEC being delivered by laypersons without formal training. Forty percent (12/31) of the systems identified in the review described a uniform access phone number for emergency medical service activation. CONCLUSIONS: Policy makers and researchers seeking to improve OHEC in low and low-middle income countries should focus on increasing the availability of transport and trained providers while improving patient access to the OHEC system. The review yielded articles with a primary focus in Africa, highlighting a need for future research in diverse geographic areas.

Burden of out-of-hospital cardiac arrest in Karachi, Pakistan: Estimation through the capture-recapture method.

OBJECTIVE: To assess the application of capture-recapture method as a potential strategy to estimate the incidence of out-of-hospital cardiac arrest. METHODS: This cross-sectional study was carried out from January to April 2013 in Karachi and comprised three public general hospitals, one public cardiac hospital, one private general hospital and two ambulance services. Two-sample capture-recapture method was used: first capture was through cardiac arrest data from two major emergency medical services and second capture was from the five teaching hospitals. Records from the hospitals and ambulance services were compared on 7 variables; name, age, gender, date and time of arrest, cause of arrest and destination hospital. Matched and unmatched cases were used in the equation to estimate the incidence of out-of-hospital cardiac arrest. RESULTS: Of the 630 out-of-hospital cardiac arrest cases reported, 191(30.3%) related to the emergency medical services records and 439(69.7%) to hospital records. The capture-recapture identified only 9(1.4%) matched cases even with the least restrictive criteria and estimated the annual out-of-hospital cardiac arrest incidence as 166/100,000 population (95% confidence interval: 142.9 to 189.6). CONCLUSIONS: Capture-recapture method could be a potential alternative for providing population level data in the absence of organised health information systems.

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.

Post-traumatic stress disorder and its predictors in emergency medical service personnel: a cross-sectional study from Karachi, Pakistan.

BACKGROUND: Emergency medical service (EMS) personnel who work to provide emergency medical care at the scene and during transportation are exposed to various kinds of stressors and are particularly susceptible to developing stress-reactions. This study assesses symptoms of post-traumatic stress disorder and its predictors among the personnel of a selected EMS in Karachi, Pakistan. METHODS: Data were gathered from 518 personnel working in an EMS setting from February to May 2014. Participants were screened for post-traumatic stress symptoms using the Impact of Event Scale-Revised (IES-R). Demographic and work-related characteristics, coping styles and the social support systems of the participants were assessed. Linear regression was used on the IES-R to identify predictors of post-traumatic stress symptoms. RESULTS: The mean score of the IES-R was 23.9 ± 12.1. EMS personnel with a dysfunctional coping style (ß = 0.67 CI 0.39 - 0.95), anxiety, and depression (ß = 0.64 CI 0.52 - 0.75) were more likely to have increased severity of post-traumatic stress symptoms. Age was found to have an inverse relationship with stress symptoms (ß = -0.17 CI 0.33 - -0.023), indicating the susceptibility of younger EMS personnel to stress. CONCLUSION: The EMS personnel in this setting were found to have a moderate level of post-traumatic stress symptoms. The significant predictors of post-traumatic stress symptoms in this EMS population were age, coping style, and levels of anxiety and depression. These predicting factors can be a potential avenue for interventions to improve the mental health of these frontline workers.

Workplace Violence and Self-reported Psychological Health: Coping with Post-traumatic Stress, Mental Distress, and Burnout among Physicians Working in the Emergency Departments Compared to Other Specialties in Pakistan.

BACKGROUND: Little is known about the mental health impact of workplace violence (WPV) among emergency physicians (EPs) working in emergency departments (EDs) in Pakistan and whether this impact varies across specialties. OBJECTIVES: Our aim was to measure the prevalence of WPV among EPs in 4 of the largest hospitals in Karachi, Pakistan; to measure the association between the experience of WPV and self-report of post-traumatic stress disorder (PTSD), depression, anxiety, and burnout; to compare the same factors across medical specialties; and to explore the coping strategies used by physicians in dealing with job-related stressors. METHODS: A cross-sectional survey was conducted among 179 physicians from 5 specialties (response rate, 92.2%) using standard questionnaires for WPV, PTSD, burnout, current mental distress, and methods of coping. RESULTS: One in 6 physicians reported experiencing a physical attack and 3 in 5 verbal abuse on the job in the previous 12 months. Pathologists were less likely to report any form of WPV compared to all other specialties. There was, however, no difference in experience of WPV between EPs and internists, surgeons, or pediatricians. One in 6 physicians screened positive for PTSD, and 2 in 5 for current anxiety and depression. There was significant comorbidity of mental distress with PTSD. Those who reported experiencing physical attack were 6.7 times more likely to report PTSD symptoms. We also found high rates of burnout (42.4% emotional exhaustion; 72.9% depersonalization) among physicians. CONCLUSION: Experience of WPV was not uniform across specialties but was generally high among Pakistani physicians. Prevention of WPV should be a high priority for health care policy makers.

Epidemiology and outcomes of out-of-hospital cardiac arrest in a developing country-a multicenter cohort study.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) is one of the leading causes of death and disability worldwide. Overall survival after an OHCA has been reported to be poor and limited studies have been conducted in developing countries. We aimed to investigate the rates of survival from OHCA and explore components of the chain of survival in a developing country. METHODS: We conducted a multicenter prospective cohort study in the emergency departments (ED) of five major public and private sector hospitals of Karachi, Pakistan from January 2013 to April 2013. Twenty-four hour data collection was performed by trained data collectors, using a structured questionnaire. All patients ≥18 years of age, presenting with OHCA of cardiac origin, were included. Patients with do-not-resuscitate status or referred from other hospitals were excluded. Our primary outcome was survival of OHCA patients at the end of ED stay. RESULTS: During the three month period, data was obtained from 310 OHCA patients. The overall survival to ED discharge was 1.6 % which decreased to 0 % at 2-months after discharge. More than half (58.3 %) of these OHCA patients were brought to the hospital in a non-EMS (emergency medical service) vehicle i.e. public or private transportation. Patients utilizing non-EMS transportation reached the hospital earlier with a median time of 23 min compared to patients utilizing any type of ambulances which had a delay of 7 min hospital reaching time (median time 30 min). However, patients utilizing ambulances with life-support facilities, as compared to all other types of pre-hospital transportation, had the shortest time to first life-support intervention (15 min). Most of the patients (92.9 %) had a witnessed cardiac arrest out of which only a small percentage (2.3 %) received bystander CPR (cardio pulmonary resuscitation). Median time from arrest to receiving first CPR was 20 min. Only 1 % of patients were found to have a shockable rhythm on first assessment. CONCLUSION: This study showed that the overall survival of OHCA is null in this population. Lack of bystander CPR and weaker emergency medical services (EMS) leading to a delay in receiving life-support interventions were some of the important observations. Poor survival emphasizes the need to standardize EMS systems, initiate public awareness programs and strengthen links in the chain of survival.

Emergency and trauma care in Pakistan: a cross-sectional study of healthcare levels.

BACKGROUND: The importance of emergency medical care for the successful functioning of health systems has been increasingly recognised. This study aimed to evaluate emergency and trauma care facilities in four districts of the province of Sindh, Pakistan. METHOD: We conducted a cross-sectional health facility survey in four districts of the province of Sindh in Pakistan using a modified version of WHO's Guidelines for essential trauma care. 93 public health facilities (81 primary care facilities, nine secondary care hospitals, three tertiary hospitals) and 12 large private hospitals were surveyed. Interviews of healthcare providers and visual inspections of essential equipment and supplies as per guidelines were performed. A total of 141 physicians providing various levels of care were tested for their knowledge of basic emergency care using a validated instrument. RESULTS: Only 4 (44%) public secondary, 3 (25%) private secondary hospitals and all three tertiary care hospitals had designated emergency rooms. The majority of primary care health facilities had less than 60% of all essential equipments overall. Most of the secondary level public hospitals (78%) had less than 60% of essential equipments, and none had 80% or more. A fourth of private secondary care facilities and all tertiary care hospitals (n=3; 100%) had 80% or more essential equipments. The average percentage score on the physician knowledge test was 30%. None of the physicians scored above 60% correct responses. CONCLUSIONS: The study findings demonstrated a gap in both essential equipment and provider knowledge necessary for effective emergency and trauma care.

Emergency care of traumatic brain injuries in Pakistan: a multicenter study.

BACKGROUND: This study assessed factors associated with emergency care outcomes and out-of-pocket treatment costs in traumatic brain injury (TBI) patients in Pakistan. METHODS: Data on TBI patients were extracted from a four-month surveillance study conducted in the emergency departments (ED) of seven large teaching hospitals. Emergency care access to physicians and imaging facilities were compared with respect to ED outcomes (discharged, admitted or dead). Out-of-pocket treatment costs (in United States dollars [USD]) were compared among different patient strata. RESULTS: ED outcomes were available for 1,787 TBI patients. Of them, most were males (79%), aged <25 years (46%) and arrived by ambulances (32%). Nurses or paramedical staff saw almost all patients (95%). Physicians with practice privileges (medical officers, residents or consultants) saw about half (55%) of them. Computerized tomography (CT) scans were performed in two of five patients (40%). Of all, 26% (n = 460) were admitted and 3% died (n = 52). Emergency care factors significantly associated with being admitted or died were arriving by ambulance (adjusted odds ratio [aOR] = 2.37, 95% confidence interval (CI) [95%CI] = 1.78-3.16); seen by medical officer/residents (aOR = 2.11; 95%CI = 1.49-2.99); and had CT scan (aOR = 2.93; 95%CI = 2.25-3.83). Out-of-pocket treatment costs at the ED were reported in 803 patients. Average costs were USD 8, (standard deviation [SD] = 23). Costs were twice as high in those arriving in ambulances (USD 20, SD = 49) or who underwent CT scans (USD 16, SD = 37). CONCLUSION: TBI patients' access to ambulance transport, experienced physicians, and imaging facilities during emergency care needs to be improved in Pakistan.

Characteristics of chest pain and its acute management in a low-middle income country: analysis of emergency department surveillance data from Pakistan.

BACKGROUND: Chest pain is one of the most frequent causes of emergency department (ED) visits in high-income countries. Little is known about chest pain patients presenting to EDs of low- and middle-income countries (LMICs). The objective of this study was to describe the characteristics of chest pain patients presenting to emergency departments (EDs) of Pakistan and to determine the utilization of ED resources in the management of chest pain patients and their outcomes. METHODS: This study used pilot active surveillance data from seven major EDs in Pakistan. Data were collected on all patients presenting to the EDs of the participating sites to seek emergency care for chest pain. RESULTS: A total of 20,435 patients were admitted to the EDs with chest pain. The majority were males (M 60%, F 40%) and the mean age was 42 years (SD+/- 14). The great majority (97%, n = 19,164) of patients were admitted to the EDs of public hospitals compared to private hospitals and only 3% arrived by ambulance. Electrocardiograms (ECGs) were used in more than half of all chest pain patients (55%, n = 10,890) while cardiac enzymes were performed in less than 5% of cases. Chest X-rays were the most frequently performed radiological procedure (21%, n = 4,135); more than half of the admitted chest pain patients were discharged from the EDs and less than 1% died in the ED. CONCLUSION: Chest pain is a common presenting complaint in EDs in Pakistan. The majority received an ECG and the use of diagnostic testing, such as cardiac enzymes, is quite uncommon.