A frog in the throat?

CLINICAL INTRODUCTION: A 44-year-old woman, with an unremarkable medical history, presented in the middle of the night with discomfort in her throat. She described being assaulted by an assailant who put his 'fist in her mouth', trying to suffocate her. On examination, she had normal observations and no signs of injury, other than scratch marks around her mouth; she reported no odynophagia and was able to swallow fluids readily. During examination, she complained that lying flat made her increasingly uncomfortable and was causing burgeoning dyspnoea. She had lateral soft tissue radiography of her neck as shown in figure 1.emermed;34/10/676/EMERMED2016205919F1F1EMERMED2016205919F1Figure 1Lateral neck soft tissue radiograph of the 44-year-old woman. QUESTION: What is the diagnosis? Caustic stricture of the oesophagusPharyngeal perforationPharyngeal pouchBoerhaave's syndrome.

Variations in sub-national road traffic fatality trends in a low-income country.

BACKGROUND: In most low- and middle-income countries (LMICs), road traffic fatality (RTF) trends are presented in aggregated form at the national level. This practice omits important information regarding RTF risk at sub-national levels. OBJECTIVE: This ecological study assesses the extent of RTF variations at different sub-national levels in Pakistan, a low-income country. MATERIALS AND METHODS: Based on official statistics, significant variations in three RTF indicators i.e. per population, per registered vehicles, and per crash were compared by regression analyses at two sub-national levels i.e. provincially (2000-2009) and district-wise (2004). RESULTS: The national RTF counts are based on data from four provinces. From 2000 to 2009, RTF per population and per registered vehicles decreased in all provinces except Balochistan. RTF per crash in Punjab decreased from 0.61 to 0.56 (beta coefficient (ß) year = -0.0082, P = <0.001), whereas in Balochistan it increased from 0.40 to 0.58 (ß year = 0.0708, P = <0.001) over the same period. District-level comparisons were possible only in Punjab where RTF per crash varied from 0.25 to 2.15 and correlated (ß = 0.50, P = 0.003) with RTF per population. CONCLUSIONS: Sub-national RTF surveillance is necessary in LMICs like Pakistan in order to prioritize available resources on high-risk jurisdictions such as the Balochistan province and districts of Punjab where high RTF per population and per crash exist.

Availability and quality of prehospital care on pakistani interurban roads.

Interurban road crashes often result in severe Road Traffic Injuries (RTIs). Prehospital emergency care on interurban roads was rarely evaluated in the low- and middle-income countries. The study highlighted the availability and quality of prehospital care facilities on interurban roads in Pakistan, a low-income country. The study setting was a 592-km-long National highway in the province of Sindh, Pakistan. Using the questionnaires adapted from the World Health Organization prehospital care guidelines [Sasser et al., 2005], managers and ambulance staff at the stations along highways were interviewed regarding the process of care, supplies in ambulances, and their experience of trauma care. Ambulance stations were either managed by the police or the Edhi Foundation (EF), a philanthropic organization. All highway stations were managed by the EF; the median distance between highway stations was 38 km (Interquartile Range [IQR]=27-46). We visited 14 stations, ten on the highway section, and four in cities, including two managed by the police. Most highway stations (n=13) received one RTI call per day. Half of stations (n=5) were inside highway towns, usually near primary or secondary-level healthcare facilities. Travel time to the nearest tertiary healthcare facility ranged from 31 to 70 minutes (median=48 minutes; IQR=30-60). Other shortcomings noted for stations were not triaging RTI cases (86%), informing hospitals (64%), or recording response times (57%). All ambulances (n=12) had stretchers, but only 58% had oxygen cylinders. The median schooling of ambulance staff (n=13) was 8 years (IQR=3-10), and the median paramedic training was 3 days (IQR=2-3). Observed shortcomings in prehospital care could be improved by public-private partnerships focusing on paramedic training, making available essential medical supplies, and linking ambulance stations with designated healthcare facilities for appropriate RTI triage.

Associations of traffic safety attitudes and ticket fixing behaviours with the crash history of Pakistani drivers.

The study assessed whether traffic safety attitudes and ticket fixing behaviours were associated with the crash history. A total of 4018 male drivers from Lahore city participated in this cross sectional study. Most were aged 18-30 years (58.7%, n = 2362), 71.9% (n = 2887) received a traffic ticket, 66.5% (n = 2672) reported previous traffic ticket fixing and 71.3% (n = 2865) considered crashes as being the will of God. Crash history was reported by 95.4% (n = 3821) of drivers, and 58.2% of them reported being involved in a road traffic crash. The likelihood of reporting a previous crash was higher in those who had received a traffic sign violation ticket [adjusted odds ratio (aOR) = 1.40; 95% confidence interval (95%CI) = 1.15-1.72], were involved in traffic ticket fixing (aOR = 1.28; 95%CI = 1.07-1.53), and considered crashes as will of God (aOR = 1.86; 95% CI = 1.57-2.22). These results suggested the need for improving traffic enforcement monitoring and safety education in Pakistan.

Epidemiology of major incidents: an EMS study from Pakistan.

BACKGROUND: A major incident is defined as an event that owing to the number of casualties has the potential to overwhelm the available resources. This paper attempts to describe the incidence and epidemiology of major incidents dealt with by a government-run emergency medical service (EMS) in the Punjab province of Pakistan, a developing country in South Asia. A major incident in this EMS is defined as any incident that produces three or more patients, or any incident in which extraordinary resources are needed. METHODS: All the calls received by an EMS Rescue 1122 were studied over a 6-month period. Calls that were defined as major incidents were identified, and further details were sought from the districts regarding these incidents. Questions specifically asked were the type of incident, time of the incident, response time for the incident, the resources needed, and the number of dead and injured casualties. Retrospective data were collected from the submitted written reports. RESULTS: Road traffic crashes (RTCs) emerged as the leading cause of a major incident in the province of Punjab and also led to the greatest number of casualties, followed by fire incidents. The total number of casualties was 3,380, out of which 73.7% were RTC victims. There was a high rate of death on the scene (10.4%). Certain other causes of major incidents also emerged, including violence, gas explosions and drowning. CONCLUSION: Road traffic crashes are the most common cause of a major incident in developing countries such as Pakistan. Injury prevention initiatives need to focus on RTCs.

Establishing a successful pre-hospital emergency service in a developing country: experience from Rescue 1122 service in Pakistan.

As in many other developing countries, emergency medical services, especially pre-hospital emergency care, has long been neglected in Pakistan. Consequently, patients are brought to the emergency departments by relatives or bystanders in private cars, taxis or any other readily available mode of transportation. Ambulances, where they exist, have barely a stretcher and arrangements for oxygen supply. Modern emergency services are considered too costly for many countries. A model of pre-hospital emergency services, called Rescue 1122 and established in Punjab province of Pakistan, is presented. The system is supported by government funding and provides a quality service. The article describes the process of establishment of the service, the organisational structure, the scope of services and the role it is currently playing in the healthcare of the region it serves.