Association of Ambulance Diversion Policy on EMS Transport and Ambulance Patient Offload Times: A Comparison of Three Strategies.

OBJECTIVES: Despite limited supporting data, hospitals continue to apply ambulance diversion (AD). Thus, we examined the impact of three different diversion policies on diversion hours, transport time (TT; leaving scene to arrival at the hospital), and ambulance patient offload time (APOT; arrival at the hospital to patient turnover to hospital staff) for 9-1-1 transports in a 22-hospital county Emergency Medical Services (EMS) system. METHODS: This retrospective study evaluated metrics during periods of three AD policies, each 27 days long: hospital-initiated (Period 1), complete suspension (Period 2), and County EMS-initiated (Period 3). We described the median transports and diversion hours, and compared the daily average and daily 90th percentile TT and APOT during the three study periods. RESULTS: Over the study period, there were 50,992 total transports in the county; Period 3 had fewer median transports per day than Period 1 (581 vs 623, p < 0.001), while Period 2 was similar to Period 1 (606 vs 623, p = 0.108). Median average daily diversion hours decreased from 98.1 h during Period 1 to zero hours during both Periods 2 (p < 0.001) and 3 (p < 0.001). Median daily average TT decreased from 18.3 min in Period 1 to 16.9 min in both Periods 2 (p < 0.001) and 3 (p < 0.001). Median daily 90th percentile TT showed a similar decrease from 30.2 min in Period 1 to 27.5 in Period 2 (p < 0.001), and to 28.1 in Period 3 (p = 0.001). Median average daily APOT was 26.0 min during Period 1, similar at 25.2 min during Period 2 (p = 0.826) and decreased to 20.4 min during Period 3 (p < 0.001). The median daily 90th percentile APOT was 53.9 min during Period 1, similar at 51.7 min during Period 2 (p = 0.553) and decreased to 40.3 min during Period 3 (p < 0.001). CONCLUSIONS: Compared to hospital-initiated AD, enacting no AD or County EMS-initiated AD was associated with less diversion time; TT and APOT showed statistically significant improvement without hospital-initiated AD but were of unclear clinical significance. EMS-initiated AD was difficult to interpret as that period had significantly fewer transports. EMS systems should consider these findings when developing strategies to improve TT, APOT, and system use of diversion.

Crouching Zookeeper, Hidden Dragon: A Case of a Komodo Dragon Bite.

BACKGROUND: The Komodo dragon (Varanus komodoensis) is the world's largest living lizard and exists in private captivity worldwide. Bites to humans are rare and have been proposed to be both infectious and venomous. CASE REPORT: A 43-year-old zookeeper was bitten on the leg by a Komodo dragon and suffered local tissue damage with no excessive bleeding or systemic symptoms to suggest envenomation. No specific therapy was administered other than local wound irrigation. The patient was placed on prophylactic antibiotics and on follow-up, which revealed no local or systemic infections, and no other systemic complaints. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Although venomous lizard bites are uncommon, prompt recognition of possible envenomation and management of these bites is important. Komodo dragon bites may produce not only superficial lacerations but also deep tissue injury, but are unlikely to produce serious systemic effects; whereas Gila monster and beaded lizard bites may cause delayed angioedema, hypotension, and other systemic symptoms. Treatment in all cases is supportive.

Emergency medicine registrar training in Africa: overview of programmes, faculty and sustainability.

BACKGROUND: The specialty of emergency medicine (EM) is new in most African countries, where emergency medicine registrar (residency) programmes (EMRPs) are at different stages of evolution and little is known about the programmes. Identifying and describing these EMRPs will facilitate planning for sustainability, collaborative efforts and curriculum development for existing and future programmes. Our objective was to identify and provide an overview of existing EMRPs in Africa and their applicant requirements, faculty characteristics and plans for sustainability. METHODS: We conducted a descriptive cross-sectional survey of Africa's EMRPs between January and December 2017, identifying programmes through an online search supplemented by discussions with African EM leaders. Leaders of all identified African EMRPs were invited to participate. Data were collected prospectively using a structured survey and are summarised with descriptive statistics. RESULTS: We identified 15 programmes in 12 countries and received survey responses from 11 programmes in 10 countries. Eight of the responding EMRPs began in 2010 or later. Only 36% of the EMRPs offer a 3-year programme. Women make up an average of 33% of faculty. Only 40% of EMRPs require faculty to be EM specialists. In smaller samples that reported the relevant data, 67% (4/6) of EMRPs have EM specialists who trained in that EMRP programme making up more than half of their faculty; 57% of Africa's 288 EMRP graduates to date are men; and an average of 39% of EMRP graduates stay on as faculty for 78% (7/9) of EMRPs. CONCLUSION: EMRPs currently produce most of their own EM faculty. Almost equal proportions of men and women have graduated from a predominantly >3-year training programme. Graduates have a variety of opportunities in academia and private practice. Future assessments may wish to focus on the evolution of these programme' curricula, faculty composition and graduates' career options.

Emergency medicine residency training in Africa: overview of curriculum.

BACKGROUND: Emergency Medicine (EM) is a rapidly developing specialty in Africa with several emergency medicine residency-training programs (EMRPs) established across the continent over the past decade. Despite rapid proliferation of the specialty, little is known about emergency care curriculum structure and content. We provide an overview of Africa's EMRPs. METHODS: This was a descriptive cross-sectional survey conducted of EMRPs in Africa between January 2017 and December 2017. Data were prospectively collected using a structured survey that was developed and administered through online data capture software, REDCap (Version 7.2.2, Vanderbilt, Nashville, TN, USA). Survey questions focused on curriculum structure and design, including clinical rotations, didactics, research, and evaluation. Data are summarized with descriptive statistics. RESULTS: The survey was sent to the leadership of 15 EMRPs in 12 different African countries and 11 (73%) responded. Five (46%) of the responding programs were started by local non-EM trained faculty, two (18%) were started by international partners, and the remainder by a combination of local non-EM faculty and international partners. Overall, Seven (64%) of the countries offer a 4-year EMRP. In General, 40% of curriculums are influenced the contents developed by African Federation for Emergency Medicine. All programs offer resident led-didactics, with a median of 12 h (Interquartile range 9-6 h) per month. All EMRPs have a mandatory research requirement. All EMRPs offer clinical rotations in the ED, Paediatrics, and Obstetrics and Gynaecology, while only 2 programs offer rotations in radiology and neonatal intensive care units. Only 46% of EMRPs have in-ED clinical supervision by specialist. CONCLUSION: The EMRPs in Africa were started by non-EM trained local faculty alone or collaboration with international partners. The curriculum offers most exposure to ED, and less exposure in radiology and neonatal intensive care. Residents are highly involved in leading didactics and less than half of the programs have in-ED specialist supervision of patient care.

Integration of energy analytics and smart energy microgrid into mobile medicine operations for the 2012 Democratic National Convention.

INTRODUCTION: Disasters create major strain on energy infrastructure in affected communities. Advances in microgrid technology offer the potential to improve "off-grid" mobile disaster medical response capabilities beyond traditional diesel generation. The Carolinas Medical Center's mobile emergency medical unit (MED-1) Green Project (M1G) is a multi-phase project designed to demonstrate the benefits of integrating distributive generation (DG), high-efficiency batteries, and "smart" energy utilization in support of major out-of-hospital medical response operations. METHODS: Carolinas MED-1 is a mobile medical facility composed of a fleet of vehicles and trailers that provides comprehensive medical care capacities to support disaster response and special-event operations. The M1G project partnered with local energy companies to deploy energy analytics and an energy microgrid in support of mobile clinical operations for the 2012 Democratic National Convention (DNC) in Charlotte, North Carolina (USA). Energy use data recorded throughout the DNC were analyzed to create energy utilization models that integrate advanced battery technology, solar photovoltaic (PV), and energy conservation measures (ECM) to improve future disaster response operations. RESULTS: The generators that supply power for MED-1 have a minimum loading ratio (MLR) of 30 kVA. This means that loads below 30 kW lead to diesel fuel consumption at the same rate as a 30 kW load. Data gathered from the two DNC training and support deployments showed the maximum load of MED-1 to be around 20 kW. This discrepancy in MLR versus actual load leads to significant energy waste. The lack of an energy storage system reduces generator efficiency and limits integration of alternative energy generation strategies. A storage system would also allow for alternative generation sources, such as PV, to be incorporated. Modeling with a 450 kWh battery bank and 13.5 kW PV array showed a 2-fold increase in potential deployment times using the same amount of fuel versus the current conventional system. CONCLUSIONS: The M1G Project demonstrated that the incorporation of a microgrid energy management system and a modern battery system maximize the MED-1 generators' output. Using a 450 kWh battery bank and 13.5 kW PV array, deployment operations time could be more than doubled before refueling. This marks a dramatic increase in patient care capabilities and has significant public health implications. The results highlight the value of smart-microgrid technology in developing energy independent mobile medical capabilities and expanding cost-effective, high-quality medical response.

Mass Immunizations: A Pocket Guide.

Numerous state, national, and global resources exist for planning and executing mass vaccination campaigns. However, they are disparate and can be complex. The COVID-19 pandemic highlighted the need for clear, easy to use mass vaccination resources. Meanwhile, annual influenza vaccination, as well as outbreaks such as mpox, demonstrates the need for continued emphasis on timely and effective vaccinations to mitigate outbreaks. This pocket guide seeks to combine relevant resources and basic steps for setting up a mass vaccination clinic, utilizing experience from COVID-19 mass vaccination sites.

Rapid Expansion and Adaptability of California Medical Disaster Teams.

The California Medical Assistance Team (CAL-MAT) program is coordinated by the California Emergency Medical Services Authority (EMSA). The program was developed to deploy and support medical personnel for disaster medical response. During the coronavirus disease (COVID-19) pandemic, the program and missions grew rapidly in response to medical surge, programs for testing and vaccination, and other concurrent disasters. CAL-MAT enrollment increased 10-fold from approximately 200 members at the beginning of 2020, to an estimated 2200 members by June 2021. This article describes the flexible use of a state-managed disaster medical response program within California and some of the challenges associated with rapid expansion and varied demands during the COVID-19 surges of March 2020-March 2022. CAL-MAT may serve as a model for development of similar state-sponsored or other disaster medical response teams.

Utilization of Alternate Care Sites During the COVID-19 Surge and Mass Care: California, 2020-2021.

The coronavirus disease (COVID-19) pandemic caused critical hospital bed and staffing shortages in parts of California for most of 2020 and 2021. Alternate Care Sites (ACS) were established in several regions to alleviate the hospital patient surge and to maximize staffed bed capacity. Over 1900 patients were successfully provided medical care (with physician, nursing, respiratory therapy, oxygen, and pharmacy services) in relatively austere settings. This paper examines the challenges faced at these ACS facilities and how adaptations were incorporated according to the changing dynamics of the COVID-19 pandemic to successfully manage higher acuity patients. ACS facilities were 1 approach to California's surge of COVID-19 patients, despite limited medical supplies and staffing.

Reduction in Hospital Transfers at a US COVID-19 Alternate Care Site: Maintaining Surge Capacity Support in Imperial County, California.

OBJECTIVE: The transfer rate for patients from an Alternate Care Site (ACS) back to a hospital may serve as a metric of appropriate patient selection and the ability of an ACS to treat moderate to severely ill patients accepted from overwhelmed health-care systems. During the coronavirus infectious disease 2019 (COVID-19) pandemic, hospitals worldwide experienced acute surges of patients presenting with acute respiratory failure. METHODS: An ACS in Imperial County, California was re-established in November 2020 to help decompress 2 local hospitals experiencing surges of COVID-19 cases. The patients treated often had multiple comorbid illnesses and required a median supplemental oxygen of 3 L/min (LPM) on admission. Numerous interventions were initiated during a 2-wk period to improve clinical care delivery. RESULTS: The objectives of this retrospective observational study are to evaluate the impact of these clinical and staff interventions at an ACS on the transfer rate and to provide issues to consider for future ACS sites managing COVID-19 patients. CONCLUSIONS: The data suggest that continuous, real-time process-improvement interventions helped reduce the transfer rate back to hospitals from 36.7% to 14.5% and that an ACS is a viable option for managing symptomatic COVID-19 positive patients requiring hospital-level care when hospitals are overburdened.

Authorship representation in global emergency medicine: a bibliometric analysis from 2016 to 2020.

INTRODUCTION: High-income country (HIC) authors are disproportionately represented in authorship bylines compared with those affiliated with low and middle-income countries (LMICs) in global health research. An assessment of authorship representation in the global emergency medicine (GEM) literature is lacking but may inform equitable academic collaborations in this relatively new field. METHODS: We conducted a bibliometric analysis of original research articles reporting studies conducted in LMICs from the annual GEM Literature Review from 2016 to 2020. Data extracted included study topic, journal, study country(s) and region, country income classification, author order, country(s) of authors' affiliations and funding sources. We compared the proportion of authors affiliated with each income bracket using Χ2 analysis. We conducted logistic regression to identify factors associated with first or last authorship affiliated with the study country. RESULTS: There were 14 113 authors in 1751 articles. Nearly half (45.5%) of the articles reported work conducted in lower middle-income countries (MICs), 23.6% in upper MICs, 22.5% in low-income countries (LICs). Authors affiliated with HICs were most represented (40.7%); 26.4% were affiliated with lower MICs, 17.4% with upper MICs, 10.3% with LICs and 5.1% with mixed affiliations. Among single-country studies, those without any local authors (8.7%) were most common among those conducted in LICs (14.4%). Only 31.0% of first authors and 21.3% of last authors were affiliated with LIC study countries. Studies in upper MICs (adjusted OR (aOR) 3.6, 95% CI 2.46 to 5.26) and those funded by the study country (aOR 2.94, 95% CI 2.05 to 4.20) had greater odds of having a local first author. CONCLUSIONS: There were significant disparities in authorship representation. Authors affiliated with HICs more commonly occupied the most prominent authorship positions. Recognising and addressing power imbalances in international, collaborative emergency medicine (EM) research is warranted. Innovative methods are needed to increase funding opportunities and other support for EM researchers in LMICs, particularly in LICs.

Drug and alcohol use in Tanzanian road traffic collision drivers.

INTRODUCTION: Road traffic collisions (RTCs) are an important public health problem in low and middle-income countries (LMIC), where 90% of RTC deaths occur. The World Health Organization has suggested strategies to address excess mortality from RTCs including efforts to combat driving after using alcohol or drugs. Data on the impact of drug and alcohol use on RTCs is limited in many low-resource settings including Tanzania. We sought to examine the prevalence of drug and alcohol use in Tanzanian RTC drivers. METHODS: This prospective, observational study was conducted in the emergency centre (EC) of Muhimbili National Hospital (MNH) in Dar es Salaam, Tanzania. We enrolled adult drivers presenting within 24 h of an RTC. We collected a saliva test of blood alcohol content (BAC) and a urine drug screen (UDS) and administered a validated substance use disorder screening tool, the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST). Patients were excluded from individual analyses if they could not produce saliva or urine or answer questions. Primary outcomes were rates of positive BAC, UDS and self-reported risky alcohol and drug use patterns. RESULTS: We screened 5264 trauma patients and enrolled 418, in whom 190 had a BAC, 364 had a UDS, and 410 had a complete ASSIST. 15 of 190 patients (7.9%) had a positive BAC, and 67/361 (18.7%) had a positive UDS for at least one drug. ASSIST scores showed 75/410 (18.3%) patients were at moderate or high risk for alcohol use disorder. Few were at risk for disordered use of other non-tobacco substances. DISCUSSION: In our population of RTC drivers, positive BAC and UDS tests were rare but many patients were at risk for an alcohol use disorder. Ideal screening for substance use in Tanzanian trauma populations may involve a combination of objective testing and a verbal screening tool.

Medical Support for California Wildfire Response.

Wildfires have become a regular seasonal disaster across the Western region of the United States. Wildfires require a multifaceted disaster response. In addition to fire suppression, there are public health and medical needs for responders and the general population in the path of the fire, as well as a much larger population impacted by smoke. This paper describes key aspects of the health and medical response to wildfires in California, including facility evacuation and shelter medical support, with emphasis on the organization, coordination, and management of medical teams deployed to fire incident base camps. This provides 1 model of medical support and references resources to help other jurisdictions that must respond to the rising incidence of large wildland fires.

Oxygen and Ventilator Logistics During California's COVID-19 Surge: When Oxygen Becomes a Scarce Resource.

The state of California, in the United States of America, has a population of nearly 40 million people and is the 5th largest economy in the world. During the coronavirus disease 2019 (COVID-19) pandemic in 2020-2021, the state experienced a medical surge that stressed its sophisticated health-care and public health system. During this period, ventilators, oxygen, and other equipment necessary for providing ventilatory support became a scarce resource in many health-care settings. When demand overwhelms supply, creative solutions are required at all levels of disaster management and health care. This study describes the disaster response by the state of California to mitigate the emergency demands for oxygen delivery resources.

Development and Implementation of Short Courses to Support the Establishment of a Prehospital System in Sub-Saharan Africa: Lessons Learned from Tanzania.

BACKGROUND: Tanzania has no formal prehospital system. The Tanzania Ministry of Health launched a formal prehospital system to address this gap. The Muhimbili University of Health and Allied Sciences (MUHAS) was tasked by the Ministry of Health to develop and implement a multicadre/provider prehospital curriculum so as to produce necessary healthcare providers to support the prehospital system. We aim to describe the process of designing and implementing the multicadre/provider prehospital short courses. The lessons learned can help inform similar initiatives in low- and middle-income countries. METHODS: MUHAS collaborated with local and international Emergency Medicine and Emergency Medical Services (EMS) specialists to form the Emergency Medical Systems Team (EMST) that developed and implemented four short courses on prehospital care. The EMST used a six-step approach to develop and implement the curriculum: problem identification, general needs assessment, targeted needs assessment, goals and objectives, educational strategies, and implementation. The EMST modified current best EMS practices, protocols, and curricula to be context and resource appropriate in Tanzania. RESULTS: We developed four prehospital short courses: Basic Ambulance Provider (BAP), Basic Ambulance Attendant (BAAT), Community First Aid (CFA), and EMS Dispatcher courses. The curriculum was vetted and approved by MUHAS, and courses were launched in November 2018. By the end of July 2019, a total of 63 BAPs, 104 BAATs, 25 EMS Dispatchers, and 287 CFAs had graduated from the programs. The main lessons learned are the importance of a practical approach to EMS development and working with the existing government cadre/provider scheme to ensure sustainability of the project; clearly defining scope of practice of EMS providers before curriculum development; and concurrent development of a multicadre/provider curriculum to better address the logistical barriers of implementation. CONCLUSION: We have provided an overview of the process of designing and implementing four short courses to train multiple cadres/providers of prehospital system providers in Tanzania. We believe this model of curricula development and implementation can be replicated in other countries across Africa.

Time for a revolution: smart energy and microgrid use in disaster response.

Modern health care and disaster response are inextricably linked to high volume, reliable, quality power. Disasters place major strain on energy infrastructure in affected communities. Advances in renewable energy and microgrid technology offer the potential to improve mobile disaster medical response capabilities. However, very little is known about the energy requirements of and alternative power sources in disaster response. A gap analysis of the energy components of modern disaster response reveals multiple deficiencies. The MED-1 Green Project has been executed as a multiphase project designed to identify energy utilization inefficiencies, decrease demands on diesel generators, and employ modern energy management strategies to expand operational independence. This approach, in turn, allows for longer deployments in potentially more austere environments and minimizes the unit's environmental footprint. The ultimate goal is to serve as a proof of concept for other mobile medical units to create strategies for energy independence.