Association of freeze-dried plasma with 24-h mortality among trauma patients at risk for hemorrhage.

BACKGROUND: Blood products form the cornerstone of contemporary hemorrhage control but are limited resources. Freeze-dried plasma (FDP), which contains coagulation factors, is a promising adjunct in hemostatic resuscitation. We explore the association between FDP alone or in combination with other blood products on 24-h mortality. STUDY DESIGN AND METHODS: This is a secondary data analysis from a cross-sectional prospective observational multicenter study of adult trauma patients in the Western Cape of South Africa. We compare mortality among trauma patients at risk of hemorrhage in three treatment groups: Blood Products only, FDP + Blood Products, and FDP only. We apply inverse probability of treatment weighting and fit a multivariable Cox proportional hazards model to assess the hazard of 24-h mortality. RESULTS: Four hundred and forty-eight patients were included, and 55 (12.2%) died within 24 h of hospital arrival. Compared to the Blood Products only group, we found no difference in 24-h mortality for the FDP + Blood Product group (p = .40) and a lower hazard of death for the FDP only group (hazard = 0.38; 95% CI, 0.15-1.00; p = .05). However, sensitivity analyses showed no difference in 24-h mortality across treatments in subgroups with moderate and severe shock, early blood product administration, and accounting for immortal time bias. CONCLUSION: We found insufficient evidence to conclude there is a difference in relative 24-h mortality among trauma patients at risk for hemorrhage who received FDP alone, blood products alone, or blood products with FDP. There may be an adjunctive role for FDP in hemorrhagic shock resuscitation in settings with significantly restricted access to blood products.

Patterns of on-scene and healthcare system trauma deaths in the Western Cape of South Africa.

BACKGROUND: Injuries account for 8% or 4.4 million deaths annually worldwide, with 90% of injury deaths occurring in low- and middle-income countries. Inter-personal violence and road traffic injuries account for most injury deaths in South Africa, with rates among the highest globally. Understanding the location, timing, and factors of trauma deaths can identify opportunities to strengthen care. METHODS: This is a retrospective cross-sectional secondary analysis of trauma deaths from 2021 to 2022 in the Western Cape of South Africa. Healthcare system trauma deaths were identified from a multicenter study paired with a dataset for on-scene (i.e., prior to ambulance or hospital) trauma deaths in the same jurisdictions. We describe locations, timing, injury factors, and cause of death. We assess associations between those factors. RESULTS: There were 2418 deaths, predominantly young men, with most (2274, 94.0%) occurring on-scene. The most frequent mechanism of injury for all deaths was firearms (32.6%), followed by road traffic collisions (17.8%). On-scene deaths (33.2%) were significantly more likely to be injured by firearms compared to healthcare system deaths (23.6%) (p-value <0.01). Most healthcare system deaths within 4-24 h of injury occurred in a hospital emergency center. Among healthcare system decedents, half died in the emergency unit. CONCLUSIONS: We identified a large burden of deaths from interpersonal violence and road traffic collisions, mostly on-scene. In addition to primary prevention, shortening delays to care can improve mortality outcomes especially for deaths occurring within 4-24 h in emergency centers.

The Effect of Prehospital Clinical Trial-Related Procedures on Scene Interval, Cognitive Load, and Error: A Randomized Simulation Study.

INTRODUCTION: Globally, very few settings have undertaken prehospital randomized controlled trials. Given this lack of experience, there is a risk that such trials in these settings may result in protocol deviations, increased prehospital intervals, and increased cognitive load, leading to error. Ultimately, this may affect patient safety and mortality. The aim of this study was to assess the effect of trial-related procedures on simulated scene interval, self-reported cognitive load, medical errors, and time to action. METHODS: This was a prospective simulation study. Using a cross-over design, ten teams of prehospital clinicians were allocated to three separate simulation arms in a random order. Simulations were: (1) Eligibility assessment and administration of freeze-dried plasma (FDP) and a hemoglobin-based oxygen carrier (HBOC), (2) Eligibility assessment and administration of HBOC, (3) Eligibility assessment and standard care. All simulations also required clinical management of hemorrhagic shock. Simulated scene interval, error rates, cognitive load (measured by NASA Task Load Index), and competency in clinical care (assessed using the Simulation Assessment Tool Limiting Assessment Bias (SATLAB)) were measured. Mean differences between simulations with and without trial-related procedures were sought using one-way ANOVA or Kruskal-Wallis test. A p-value of <0.05 within the 95% confidence interval was considered significant. RESULTS: Thirty simulations were undertaken, representing our powered sample size. The mean scene intervals were 00:16:56 for Simulation 1 (FDP and HBOC), 00:17:22 for Simulation 2 (HBOC only), and 00:14:24 for Simulation 3 (standard care). Scene interval did not differ between the groups (p = 0.27). There were also no significant differences in error rates (p = 0.28) or cognitive load (p = 0.67) between the simulation groups. There was no correlation between cognitive load and error rates (r = 0.15, p = 0.42). Competency was achieved in all the assessment criteria for all simulation groups. CONCLUSION: In a simulated environment, eligibility screening, performance of trial-related procedures, and clinical management of patients with hemorrhagic shock can be completed competently by prehospital advanced life support clinicians without delaying transport or emergency care. Future prehospital clinical trials may use a similar approach to help ensure graded and cautious implementation of clinical trial procedures into prehospital emergency care systems.

Emergency medicine doctoral education in Africa: a scoping review of the published literature.

BACKGROUND: While Africa accounts for a significant proportion of world population, and disease and injury burden, it produces less than 1% of the total research output within emergency care. Emergency care research capacity in Africa may be expanded through the development of doctoral programmes that aim to upskill the PhD student into an independent scholar, through dedicated support and structured learning. This study therefore aims to identify the nature of the problem of doctoral education in Africa, thereby informing a general needs assessment within the context of academic emergency medicine. METHODS: A scoping review, utilising an a priori, piloted search strategy was conducted (Medline via PubMed and Scopus) to identify literature published between 2011 and 2021 related to African emergency medicine doctoral education. Failing that, an expanded search was planned that focused on doctoral education within health sciences more broadly. Titles, abstracts, and full texts were screened for inclusion in duplicate, and extracted by the principal author. The search was rerun in September 2022. RESULTS: No articles that focused on emergency medicine/care were found. Following the expanded search, a total of 235 articles were identified, and 27 articles were included. Major domains identified in the literature included specific barriers to PhD success, supervision practices, transformation, collaborative learning, and research capacity improvement. CONCLUSIONS: African doctoral students are hindered by internal academic factors such as limited supervision and external factors such as poor infrastructure e.g. internet connectivity. While not always feasible, institutions should offer environments that are conducive to meaningful learning. In addition, doctoral programmes should adopt and enforce gender policies to help alleviate the gender differences noted in PhD completion rates and research publication outputs. Interdisciplinary collaborations are potential mechanisms to develop well-rounded and independent graduates. Post-graduate and doctoral supervision experience should be a recognised promotion criterion to assist with clinician researcher career opportunities and motivation. There may be little value in attempting to replicate the programmatic and supervision practices of high-income countries. African doctoral programmes should rather focus on creating contextual and sustainable ways of delivering excellent doctoral education.

Changes in trauma-related emergency medical services during the COVID-19 lockdown in the Western Cape, South Africa.

BACKGROUND: To limit virus spread during the COVID pandemic, extensive measures were implemented around the world. In South Africa, these restrictions included alcohol and movement restrictions, factors previously linked to injury burden in the country. Consequently, reports from many countries, including South Africa, have shown a reduction in trauma presentations related to these restrictions. However, only few studies and none from Africa focus on the impact of the pandemic restrictions on the Emergency Medical System (EMS). METHODS: We present a retrospective, observational longitudinal study including data from all ambulance transports of physical trauma cases collected during the period 2019-01-01 and 2021-02-28 from the Western Cape Government EMS in the Western Cape Province, South Africa (87,167 cases). Within this timeframe, the 35-days strictest lockdown level period was compared to a 35-days period prior to the lockdown and to the same 35-days period in 2019. Injury characteristics (intent, mechanism, and severity) and time were studied in detail. Ambulance transport volumes as well as ambulance response and on-scene time before and during the pandemic were compared. Significance between indicated periods was determined using Chi-square test. RESULTS: During the strictest lockdown period, presentations of trauma cases declined by > 50%. Ambulance transport volumes decreased for all injury mechanisms and proportions changed. The share of assaults and traffic injuries decreased by 6% and 8%, respectively, while accidental injuries increased by 5%. The proportion of self-inflicted injuries increased by 5%. Studies of injury time showed an increased share of injuries during day shift and a reduction of total injury volume during the weekend during the lockdown. Median response- and on-scene time remained stable in the time-periods studied. CONCLUSION: This is one of the first reports on the influence of COVID-19 related restrictions on EMS, and the first in South Africa. We report a decline in trauma related ambulance transport volumes in the Western Cape Province as well as changes in injury patterns, largely corresponding to previous findings from hospital settings in South Africa. The unchanged response and on-scene times indicate a well-functioning EMS despite pandemic challenges. More studies are needed, especially disaggregating the different restrictions.

A Retrospective Geospatial Simulation Study of Helicopter Emergency Medical Services' Potential Time Benefit Over Ground Ambulance Transport in Northern South Africa.

OBJECTIVE: One of the most important benefits of helicopter emergency medical services (HEMS) is a time benefit, either through expedited access to the casualty or a reduction in the transport time to definitive care. However, HEMS utilization does not come without risk to the public and crew or at an insignificant cost. Cost is an essential consideration for health policy decisions, especially in low- to middle-income countries, such as South Africa. The aim of this study was to determine whether there is a time benefit of HEMS dispatch in South Africa compared with simulated driving time. A secondary aim was to determine the distance from the incident site to the hospital at which a time benefit can be guaranteed. METHODS: A retrospective study was undertaken by comparing the prehospital times of patients who underwent HEMS transportation with simulated ground emergency medical services (GEMS) transportation times. Handwritten patient records of actual flights were reviewed and analyzed. The actual flight times recorded were used to calculate the helicopter transport time, activation to scene time, scene time, and scene to hospital time. Times were assigned based on a nonsimultaneous dispatch model, as is used in South Africa. For each helicopter mission, Google Maps (Google Inc, Mountain View, CA) was used to simulate the fastest ground route from the same location of the incident to the same receiving hospital corrected for typical traffic trends. The actual HEMS and simulated GEMS times were compared using the paired t-test. Linear regression analysis was performed to determine a minimum driving distance at which HEMS provides a time benefit. RESULTS: A total of 118 HEMS transports were analyzed, the majority of which were trauma related (n = 115, 97%). HEMS transport resulted in a mean time deficit of -15 minutes (95% confidence interval, -18 to -11; P < .05) compared with simulated GEMS drive times. After regression, HEMS transport provides a time benefit at a driving distance greater than 119 km. CONCLUSION: The current study demonstrated that there was rarely a time benefit for actual primary emergency responses when HEMS was used compared with simulated driving time of GEMS transport. Using a nonsimultaneous dispatch model, a time benefit only occurs when the driving distance from the incident site to the hospital is greater than 119 km. There is an urgent need to critically evaluate HEMS utilization in the South African context.

A retrospective descriptive analysis of non-physician-performed prehospital endotracheal intubation practices and performance in South Africa.

INTRODUCTION: Prehospital advanced airway management, including endotracheal intubation (ETI), is one of the most commonly performed advanced life support skills. In South Africa, prehospital ETI is performed by non-physician prehospital providers. This practice has recently come under scrutiny due to lower first pass (FPS) and overall success rates, a high incidence of adverse events (AEs), and limited evidence regarding the impact of ETI on mortality. The aim of this study was to describe non-physician ETI in a South African national sample in terms of patient demographics, indications for intubation, means of intubation and success rates. A secondary aim was to determine what factors were predictive of first pass success. METHODS: This study was a retrospective chart review of prehospital ETIs performed by non-physician prehospital providers, between 01 January 2017 and 31 December 2017. Two national private Emergency Medical Services (EMS) and one provincial public EMS were sampled. Data were analysed descriptively and summarised. Logistic regression was performed to evaluate factors that affect the likelihood of FPS. RESULTS: A total of 926 cases were included. The majority of cases were adults (n = 781, 84.3%) and male (n = 553, 57.6%). The most common pathologies requiring emergency treatment were head injury, including traumatic brain injury (n = 328, 35.4%), followed by cardiac arrest (n = 204, 22.0%). The mean time on scene was 46 minutes (SD = 28.3). The most cited indication for intubation was decreased level of consciousness (n = 515, 55.6%), followed by cardiac arrest (n = 242, 26.9%) and ineffective ventilation (n = 96, 10.4%). Rapid sequence intubation (RSI, n = 344, 37.2%) was the most common approach. The FPS rate was 75.3%, with an overall success rate of 95.7%. Intubation failed in 33 (3.6%) patients. The need for ventilation was inversely associated with FPS (OR = 0.42, 95% CI: 0.20-0.88, p = 0.02); while deep sedation (OR = 0.56, 95% CI: 0.36-0.88, p = 0.13) and no drugs (OR = 0.47, 95% CI: 0.25-0.90, p = 0.02) compared to RSI was less likely to result in FPS. Increased scene time (OR = 0.99, 95% CI: 0.985-0.997, p < 0.01) was inversely associated FPS. CONCLUSION: This is one of the first and largest studies evaluating prehospital ETI in Africa. In this sample of ground-based EMS non-physician ETI, we found success rates similar to those reported in the literature. More research is needed to determine AE rates and the impact of ETI on patient outcome. There is an urgent need to standardise prehospital ETI reporting in South Africa to facilitate future research.

Predicting mortality among septic patients presenting to the emergency department-a cross sectional analysis using machine learning.

BACKGROUND: Sepsis is a life-threatening condition, causing almost one fifth of all deaths worldwide. The aim of the current study was to identify variables predictive of 7- and 30-day mortality among variables reflective of the presentation of septic patients arriving to the emergency department (ED) using machine learning. METHODS: Retrospective cross-sectional design, including all patients arriving to the ED at Södersjukhuset in Sweden during 2013 and discharged with an International Classification of Diseases (ICD)-10 code corresponding to sepsis. All predictions were made using a Balanced Random Forest Classifier and 91 variables reflecting ED presentation. An exhaustive search was used to remove unnecessary variables in the final model. A 10-fold cross validation was performed and the accuracy was described using the mean value of the following: AUC, sensitivity, specificity, PPV, NPV, positive LR and negative LR. RESULTS: The study population included 445 septic patients, randomised to a training (n = 356, 80%) and a validation set (n = 89, 20%). The six most important variables for predicting 7-day mortality were: "fever", "abnormal verbal response", "low saturation", "arrival by emergency medical services (EMS)", "abnormal behaviour or level of consciousness" and "chills". The model including these variables had an AUC of 0.83 (95% CI: 0.80-0.86). The final model predicting 30-day mortality used similar six variables, however, including "breathing difficulties" instead of "abnormal behaviour or level of consciousness". This model achieved an AUC = 0.80 (CI 95%, 0.78-0.82). CONCLUSIONS: The results suggest that six specific variables were predictive of 7- and 30-day mortality with good accuracy which suggests that these symptoms, observations and mode of arrival may be important components to include along with vital signs in a future prediction tool of mortality among septic patients presenting to the ED. In addition, the Random Forests appears to be a suitable machine learning method on which to build future studies.

South African paramedic perspectives on prehospital palliative care.

BACKGROUND: Palliative care is typically performed in-hospital. However, Emergency Medical Service (EMS) providers are uniquely positioned to deliver early palliative care as they are often the first point of medical contact. The aim of this study was to gather the perspectives of advanced life support (ALS) providers within the South African private EMS sector regarding pre-hospital palliative care in terms of its importance, feasibility and barriers to its practice. METHODS: A qualitative study design employing semi-structured one-on-one interviews was used. Six interviews with experienced, higher education qualified, South African ALS providers were conducted. Content analysis, with an inductive-dominant approach, was performed to identify categories within verbatim transcripts of the interview audio-recordings. RESULTS: Four categories arose from analysis of six interviews: 1) need for pre-hospital palliative care, 2) function of pre-hospital healthcare providers concerning palliative care, 3) challenges to pre-hospital palliative care and 4) ideas for implementing pre-hospital palliative care. According to the interviewees of this study, pre-hospital palliative care in South Africa is needed and EMS providers can play a valuable role, however, many challenges such as a lack of education and EMS system and mindset barriers exist. CONCLUSION: Challenges to pre-hospital palliative care may be overcome by development of guidelines, training, and a multi-disciplinary approach to pre-hospital palliative care.

Helicopter Emergency Medical Services in Trauma Does Not Influence Mortality in South Africa.

OBJECTIVE: Sub-Saharan Africa carries a large trauma burden. Helicopter emergency medical services (HEMS) have been suggested to reduce prehospital time and mortality. It is not clear whether HEMS infers a mortality benefit over ground transport in South Africa. This study aimed to determine whether HEMS improved 30-day mortality over ground emergency medical services (GEMS). METHODS: A retrospective, case-control study was undertaken for major trauma patients transported to a private trauma center in Johannesburg. A 1-year cohort of HEMS patients was extracted and matched to GEMS patients based on mechanism, injury severity or percentage of the total body surface area burned, age, sex, and comorbidities. The odds ratio (OR) for 30-day mortality was calculated to determine the risk of death. RESULTS: A total of 822 cases (HEMS: 272 [33%], GEMS: 550 [67%]) were reviewed. We included 410 patients in the matched cohort with equal distribution between transportation modes. The OR for mortality in the total cohort was 2.69 (95% confidence interval, 1.6-4.6; P = .003) for HEMS patients, whereas in the matched cohort the OR was 1.35 (95% confidence interval, 0.5-3.4; P = .503) for patients transported by HEMS. CONCLUSION: In a matched cohort of major trauma patients, HEMS does not seem to improve mortality over GEMS. These results might reflect the South African HEMS dispatch model.

Clinical Interventions Account for Scene Time in a Helicopter Emergency Medical Service in South Africa.

INTRODUCTION: Helicopter emergency medical services (HEMS) have been associated with a prolonged scene time, compromising the time benefit in an urban setting. Therefore, the clinical benefit offered through additional equipment, skills, and experience of HEMS crews must be investigated to propose the value of HEMS. This study aimed at establishing whether HEMS scene time was associated with the number of clinical interventions performed and improved patient stability. METHOD: This retrospective, cross-sectional chart review included all primary HEMS cases from June 1, 2013, to May 31, 2015, from a South African helicopter service and extracted the number of clinical interventions and patient stability using the Mainz Emergency Evaluation Score (MEES). We correlated this with scene time using analysis of variance. RESULTS: Five hundred fourteen clinical interventions were performed on 204 patients. A median of 2 clinical interventions per patient was performed on scene. Performing 1 additional clinical intervention was associated with an approximate 4-minute increase in on-scene time. Some improvement in patient stability was shown by a mean change in the MEES of 0.65 after on-scene intervention, but this did not reach MEES clinical cutoff measures. CONCLUSION: The number of clinical interventions performed by helicopter crews can account for scene time in a South African HEMS. The clinical interventions performed by helicopter crews tend to have a positive effect on patient stability.

Attitudes of prehospital providers on transport decision-making in the management of patients with a suicide attempt refusing care: A survey based on the Mental Health Care Act of 2002.

BACKGROUND: Given the frequency of suicidal patients making attempts prior to a completed suicide, emergency access to mental health care services could lead to significant reduction in morbidity and mortality for these patients. AIM: To describe the attitudes of prehospital providers and describe transport decision-making around the management of patients with a suicide attempt. SETTING: Cape Town Metropole. METHODS: A cross-sectional, vignette-based survey was used to collect data related to training and knowledge of the Mental Health Care Act, prehospital transport decision-making and patient management. RESULTS: Patients with less dramatic suicidal history were more likely to be discharged on scene. Few respondents reported the use of formal suicide evaluation tools to aid their decision. Respondents displayed negative attitudes towards suicidal patients. Some respondents reported returning to find a suicidal patient dead, while others reported patient attempts at suicide when in their care. Eighty per cent of respondents had no training in the management of suicidal patients, while only 7.0% had specific training in the Mental Health Care Act. CONCLUSION: A critical lack in the knowledge, training and implementation of the Mental Health Care Act exists amongst prehospital providers within the Western Cape. A further concern is the negative feelings towards suicidal patients and the lack of commitment to transporting patients to definitive care. It is essential to urgently develop training programmes to ensure that prehospital providers are better equipped to deal with suicidal patients.

Emergency medical services impact evaluation approaches in low and middle-income countries.

There is a strong need to critically consider the neocolonial context when discussing the impact evaluation of Eemergency Medical Services (EMS) systems in many low to middle-income countries. Many of these countries have faced exploitation and settler colonialism, and in today's world the aftermath of these political-economic unequal power dynamics persists through neocolonialism. "Solutions" to prehospital care and related donor-driven development sector aid programs are typically orchestrated by high-income countries in the Global North, many of whom directly benefited from centuries of colonizing the Global South. This perpetuates the financial and technocratic dependency of many low to middle-income countries. Traditional Global North-led impact assessment typically revolves around mortality outcomes. This is problematic because singularly tracking mortality can obscure the influence of important factors at play beyond the emergency response incident itself, such as morbidity and socioeconomic privilege. This is why process indicators such as response times and economic impacts on first responders and communities are crucial. Hence, instead of trying to develop a one-size-fits-all impact assessment criteria for all the diverse prehospital care system contexts across the world, it is important to focus on enabling bottom-up, community-led, and participatory approaches to finding context-tailored solutions. A key element of this should be the co-creation of the measures of success themselves with the community stakeholders. Such a decolonial holistic approach may then help put the spotlight on often neglected important measures, such as the inclusion of underprivileged minorities in emergency response and the level of protection against catastrophic health care expenditure built into EMS systems. In doing so, it can encourage a monitoring and evaluation shift from short-term mortality to long-term wellbeing, taking into account cultural contexts about what "wellbeing" entails. Furthermore, it is important to challenge the taken-for-granted notion that in low to middle-income countries, EMS systems are solely for trauma and medical emergencies. It is also important to consider (with the dialogue led by the local stakeholders) what sustainability would look like, and how resources accordingly should be allocated, in those regions in low to middle-income countries where there is political and economic volatility as a consequence of continuing neocolonial hegemony.

Consensus-based quality standards for emergency departments in Palestine.

OBJECTIVES: The present study aimed to establish appropriate quality standards for emergency departments (EDQS) in Palestine. METHODS: The study comprised four phases. First, a comprehensive literature review was conducted to develop a framework for assessing healthcare services in EDs. Second, the initial set of EDQS was developed based on the review findings. Third, local experts provided feedback on the EDQS, suggesting additional standards, and giving recommendations. This feedback was analysed to create a preliminary set of EDQS. Finally, an expanded group of local emergency care experts evaluated the preliminary set, providing feedback on content and structure to contribute to the final set of EDQS. FINDINGS: We identified quality domains in EDs and categorised them into clinical and administrative pathways. The clinical pathway comprises 39 standards across 7 subdomains: triage, treatment, transportation, medication safety, patient flow and medical diagnostic services. Expert consensus was achieved on 87.5% of these standards. The administrative domain includes 64 consensus-based standards across 9 subdomains: documentation, information management systems, access-location, design, leadership, management, workforce staffing, training, equipment, supplies, capacity-resuscitation rooms, resources for a safe working environment, performance indicators and patient safety-infection prevention and control programmes. CONCLUSION: This study employed a rigorous approach to identify QS for EDs in Palestine. The multiphase consensus process ensured the appropriateness of the developed EDQS. Inclusion of diverse perspectives enriched the content. Future studies will validate and refine the standards based on feedback. The EDQS has potential to enhance emergency care in Palestine and serve as a model for other regions facing similar challenges.

A resuscitation systems analysis for South Africa: A narrative review.

With a growing incidence in cardiovascular diseases in Africa, including South Africa, and with it a greater incidence of out-of-hospital cardiac arrest (OHCA) there is a need to understand the readiness of these emergency care systems to support a response. Yet, OHCA is expensive and requires comprehensive development across an entire chain of survival in order to gain any benefit in mortality or morbidity. In this narrative review, we provide a resuscitation systems analysis using the Global Resuscitation Alliance's Frame of Survival. We provide evidence or commentary on the elements of the outer frame and inner frame, and make an assessment of the South African system's readiness to support OHCA care, and provide suggestions for priority areas that need to be developed. The South African resuscitation system demonstrates reasonable readiness to respond to OHCA but is characterised by considerable variation and fragmentation. Given the cost ineffectiveness of many interventions and the anticipated rise in OHCA incidence, there is a pressing need for context-specific strategies in South Africa. These strategies should focus on enhancing both outcomes and resource efficiency, while respecting community ethics and sociocultural dynamics.

Patient Preferences for Out-of-Hospital Cardiac Arrest Care in South Africa: A Discrete Choice Experiment.

OBJECTIVE: This study examined the trade-offs low-resource setting community members were willing to make in regard to out-of-hospital cardiac arrest care using a discrete choice experiment survey. METHODS: We administered a discrete choice experiment survey to a sample of community members 18 years or older across South Africa between April and May 2022. Participants were presented with 18 paired choice tasks comprised of 5 attributes (distance to closest adequate facility, provider of care, response time, chances of survival, and transport cost) and a range of 3 to 5 levels. We used mixed logit models to evaluate respondents' preferences for selected attributes. RESULTS: Analyses were based on 2228 responses and 40 104 choice tasks. Patients valued care with the shortest response time, delivered by the highest qualified individuals, which placed them within the shortest distance of an adequate facility, gave them the highest chance of survival, and costed the least. In addition, patients preferred care delivered by their family members over care delivered by the lay public. The highest mean willingness-to-pay for increased survival is 11 699 South African rand (ZAR), followed by distance to health facility (8108 ZAR), and response time (5678 ZAR), and the lowest for increasing specialization of provider (1287 ZAR). CONCLUSIONS: In low-resource settings, it may align with patients' preference to include targeted resuscitation training for family members of individuals with high-risk for cardiac arrest as a part of out-of-hospital cardiac arrest intervention strategies.

Recognition and Awareness of Sepsis by First-Aid Providers in Adults With Suspected Infection: A Scoping Review.

Sepsis accounts for a significant proportion of preventable deaths worldwide and early treatment has been found to be a mainstay of decreasing mortality. Early identification of sepsis in the first-aid setting is critical as this results in a shorter time to hospital presentation and management with antibiotics and initial resuscitation. Our aim was to explore the existing literature related to either sepsis recognition or awareness of sepsis by first-aid providers who are evaluating an adult suspected of an acute infection. Our scoping review was performed as part of the International Liaison Committee on Resuscitation's (ILCOR) continuous evidence evaluation process to update the 2024 ILCOR Consensus on Science with Treatment Recommendations. We searched Embase, Medline, and Cochrane databases from their inception to January 17, 2023, with updated searches performed on November 21, 2023, and December 2, 2023. The gray literature search was conducted on August 29, 2023. The population included adults presenting with an acute illness exhibiting signs and symptoms of a severe infection. Outcomes included sepsis recognition or awareness of sepsis by a lay first-aid provider. After reviewing 4380 potential sources, four reviews (three systematic reviews and one scoping review), 11 observational studies, and 27 websites met the inclusion criteria. No study directly addressed our PICOST (Population, Intervention, Comparator, Outcomes, Study Design, and Timeframe) question as none were performed in the first-aid setting. Three systematic reviews and nine observational studies that assessed the ability of early warning scores to detect sepsis and predict adverse outcomes secondary to sepsis had inconsistent results, but many found the screening tools to be useful. One scoping review and one observational study found public knowledge and awareness of sepsis to be variable and dependent upon healthcare employment, location, education level, ethnicity, sex, and age. Signs and symptoms associated with sepsis as listed by gray literature sources fell primarily under nine general categories as a means of educating the public on sepsis recognition. Although this scoping review did not identify any studies that directly addressed our outcomes, it highlights the need for future research to better understand the recognition of sepsis in first-aid settings.

Safety of Bioplasma FDP and Hemopure in rhesus macaques after 30% hemorrhage.

Objectives: Prehospital transfusion can be life-saving when transport is delayed but conventional plasma, red cells, and whole blood are often unavailable out of hospital. Shelf-stable products are needed as a temporary bridge to in-hospital transfusion. Bioplasma FDP (freeze-dried plasma) and Hemopure (hemoglobin-based oxygen carrier; HBOC) are products with potential for prehospital use. In vivo use of these products together has not been reported. This study assessed the safety of intravenous administration of HBOC+FDP, relative to normal saline (NS), in rhesus macaques (RM). Methods: After 30% blood volume removal and 30 minutes in shock, animals were resuscitated with either NS or two units (RM size adjusted) each of HBOC+FDP during 60 minutes. Sequential blood samples were collected. After neurological assessment, animals were killed at 24 hours and tissues collected for histopathology. Results: Due to a shortage of RM during the COVID-19 pandemic, the study was stopped after nine animals (HBOC+FDP, seven; NS, two). All animals displayed physiologic and tissue changes consistent with hemorrhagic shock and recovered normally. There was no pattern of cardiovascular, blood gas, metabolic, coagulation, histologic, or neurological changes suggestive of risk associated with HBOC+FDP. Conclusion: There was no evidence of harm associated with the combined use of Hemopure and Bioplasma FDP. No differences were noted between groups in safety-related cardiovascular, pulmonary, renal or other organ or metabolic parameters. Hemostasis and thrombosis-related parameters were consistent with expected responses to hemorrhagic shock and did not differ between groups. All animals survived normally with intact neurological function. Level of evidence: Not applicable.

Burnout among advanced life support paramedics in Johannesburg, South Africa.

OBJECTIVES: To establish the prevalence of burnout among advanced life support (ALS) paramedics in Johannesburg, South Africa and assess the relationship between burnout and a number of demographic characteristics of the sampled ALS paramedics. DESIGN: Cross-sectional internet-based survey. METHOD: Survey invitations were sent via email to 98 registered ALS paramedics in the Johannesburg area. The survey questionnaire was created by combining the Copenhagen Burnout Inventory (CBI) with numerous distractor questions. Burnout was defined as a CBI score >50. Descriptive analysis was performed and results subjected to Chi-square testing in order to establish dependencies between burnout scores and demographic factors. RESULTS: A 46% (n=45) response rate was obtained. Forty responses were eligible for analysis. 30% of these respondents had total burnout according to their CBI score, while 63% exhibited some degree of burnout in one of the CBI subcategories. The results of the subcategory analyses showed that 23% of respondents experienced burnout in the patient care-related category, 38% experienced burnout in the work-related category and 53% experienced burnout in the personal burnout category. There were no statistical differences in the burnout scores according to gender (p=0.292), position held (p=0.193), employment sector (p=0.414), years of experience (p=0.228) or qualification (p=0.846). Distractor questions showed that paramedics feel overworked, undervalued, poorly remunerated and unsupported by their superiors. CONCLUSION: This sample of Johannesburg-based paramedics had a greater prevalence of burnout compared with their international counterparts. Further research is needed to identify the true extent of this problem.