The coronavirus disease 2019 (COVID-19) pandemic will have a large impact in low-resource settings (LRS). 20% of COVID-19 patients become critically ill with hypoxia or respiratory failure (figure).1Wu Z McGoogan JM Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: Summary of a report of 72314 cases from the Chinese Center for Disease Control and Prevention.JAMA. 2020; (published online Feb 25.)DOI:10.1001/jama.2020.2648Crossref Scopus (12618) Google Scholar Critical illness, describing any acute life-threatening condition, is receiving increased attention in global health because of its large disease burden and population impact.2Adhikari NK Fowler RA Bhagwanjee S Rubenfeld GD Critical care and the global burden of critical illness in adults.Lancet. 2010; 376: 1339-1346Summary Full Text Full Text PDF PubMed Scopus (840) Google Scholar Before the COVID-19 pandemic, growing evidence suggested that the care of critical illness was overlooked in LRS—hospitals cannot, or do not, prioritise emergency and critical care.3Reynolds T Sawe HR Rubiano A Sang Do S Wallis L Mock C Strengthening health systems to provide emergency care: DCP3 disease control priorities. World Bank, Washington, DC2018Google Scholar Most critically ill patients are cared for in emergency units and general wards and do not have access to advanced care in intensive care units (ICUs). Data from hospital wards in Malawi showed that 89% of hypoxic patients (oxygen saturation <90%) were not receiving oxygen, and 53% of unconscious patients (Glasgow Coma Scale <9) were being nursed supine without a protected airway (unpublished data). The COVID-19 pandemic will lead to a surge in the number of critically ill patients.4Hopman J Allegranzi B Mehtar S Managing COVID-19 in low- and middle-income countries.JAMA. 2020; (published online March 17.)DOI:10.1001/jama.2020.4169Crossref PubMed Scopus (351) Google Scholar Hospitals throughout the world will become overwhelmed, and care will be provided at a lower resource level than usual. Along with preventive measures and infection control, the clinical care of these patients will be a fundamental determinant of the pandemic's overall impact. Unfortunately, the headline figures of ICU requirements for COVID-19 patients in resource-rich settings are masking the need for essential care. Attention is directed towards expensive, high-tech equipment that demands highly trained providers while neglecting low-cost essential care. To avoid this neglect, we recommend a primary policy focus on basic, effective actions with potential population impact. A conceptual framework has recently been proposed that illustrates the need for hospital readiness and good quality clinical practice for the dual aspects of identification and care of critically ill patients (appendix).5Schell CO Gerdin Wärnberg M Hvarfner A et al.The global need for essential emergency and critical care.Crit Care. 2018; 22: 284Crossref PubMed Scopus (70) Google Scholar Hospitals should establish effective systems for triage and essential care in emergency units and wards, including patient separation and staff safety. User-friendly, concise protocols should be developed, disseminated, and implemented for good quality and feasible clinical care, with WHO's leadership and through national authorities. Simple physiological signs have been shown to identify critical illness, and single-parameter systems might be easier to use than compound scores. The central role of oxygen therapy should be emphasised, oxygen supplies and delivery systems secured, and guidelines for sustainable and appropriate use issued. Other essential care includes a head-up patient position, suction, and simple chest physiotherapy. When human resources are limited, such care can be implemented by less trained health workers or vital-signs assistants through a protocolised approach and task sharing. Quality essential care of critical illness could have a large positive effect on mortality even without ICUs. It would ameliorate the fatalism and passivity that arises from an absence of high-resource treatment options. Moreover, provision of essential care could prevent progression to multi-organ failure, reducing the burden on limited ICU capacity. The ability of health services in LRS and throughout the world to provide good quality essential care of critical illness must be greatly and urgently increased. TB reports personal fees for a consultancy in Global Critical Care from the Wellcome Trust, unrelated to this Correspondence. DFM reports chairing the UK National Institutes of Health Research (NIHR) and Medical Research Council funding committee for COVID-19 for therapeutics and vaccines. DFM also reports personal fees from consultancy about acute respiratory disease for GlaxoSmithKline, Boehringer Ingelheim, and Bayer, unrelated to this Correspondence; in addition, DFM's institution has received funds from grants from the UK NIHR, Wellcome Trust, Innovate UK, and others, he has a patent issued to his institution for a treatment for acute respiratory distress syndrome, and he is Director of Research for the Intensive Care Society and NIHR Efficacy and Mechanism Evaluation Programme Director. All other authors declare no competing interests. Download .pdf (.12 MB) Help with pdf files Supplementary appendix
Objective The South African Triage Scale (SATS) has demonstrated good validity in the EDs of Médecins Sans Frontières (MSF)-supported sites in Afghanistan and Haiti; however, corresponding reliability in these settings has not yet been reported on. This study set out to assess the inter-rater and intrarater reliability of the SATS in four MSF-supported EDs in Afghanistan and Haiti (two trauma-only EDs and two mixed (including both medical and trauma cases) EDs). Methods Under classroom conditions between December 2013 and February 2014, ED nurses at each site assigned triage ratings to a set of context-specific vignettes (written case reports of ED patients). Inter-rater reliability was assessed by comparing triage ratings among nurses; intrarater reliability was assessed by asking the nurses to retriage 10 random vignettes from the original set and comparing these duplicate ratings. Inter-rater reliability was calculated using the unweighted kappa, linearly weighted kappa and quadratically weighted kappa (QWK) statistics, and the intraclass correlation coefficient (ICC). Intrarater reliability was calculated according to the percentage of exact agreement and the percentage of agreement allowing for one level of discrepancy in triage ratings. The correlation between years of nursing experience and reliability of the SATS was assessed based on comparison of ICCs and the respective 95% CIs. Results A total of 67 nurses agreed to participate in the study: In Afghanistan there were 19 nurses from Kunduz Trauma Centre and nine from Ahmed Shah Baba; in Haiti, there were 20 nurses from Martissant Emergency Centre and 19 from Tabarre Surgical and Trauma Centre. Inter-rater agreement was moderate across all sites (ICC range: 0.50–0.60; QWK range: 0.50–0.59) apart from the trauma ED in Haiti where it was moderate to substantial (ICC: 0.58; QWK: 0.61). Intrarater agreement was similar across the four sites (68%–74% exact agreement); when allowing for a one-level discrepancy in triage ratings, intrarater reliability was near perfect across all sites (96%–99%). No significant correlation was found between years of nursing experience and reliability. Conclusion The SATS has moderate reliability in different EDs in Afghanistan and Haiti. These findings, together with concurrent findings showing that the SATS has good validity in the same settings, provide evidence to suggest that SATS is suitable in trauma-only and mixed EDs in low-resource settings.
Motor vehicle crashes are a leading cause of morbidity and mortality in the United Kingdom. Airbags drastically reduce both morbidity and mortality from crashes, but with the increased use of airbags there has been a corresponding increase in the number of injuries attributable to these devices. This review discusses the history and mechanism of action of airbags, along with the spectrum of injuries seen as a result of their deployment, and future advances that may be of benefit in increasing motor vehicle safety.
The goal of this study was to identify publications in the medical literature that support the efficacy or value of Emergency Medicine (EM) as a medical specialty and of clinical care delivered by trained emergency physicians. In this study we use the term "value" to refer both to the "efficacy of clinical care" in terms of achieving desired patient outcomes, as well as "efficiency" in terms of effective and/or cost-effective utilization of healthcare resources in delivering emergency care. A comprehensive listing of publications describing the efficacy or value of EM has not been previously published. It is anticipated that the accumulated reference list generated by this study will serve to help promote awareness of the value of EM as a medical specialty, and acceptance and development of the specialty of EM in countries where EM is new or not yet fully established. The January 1995 to October 2010 issues of selected journals, including the EM journals with the highest article impact factors, were reviewed to identify articles of studies or commentaries that evaluated efficacy, effectiveness, and/or value related to EM as a specialty or to clinical care delivered by EM practitioners. Articles were included if they found a positive or beneficial effect of EM or of EM physician-provided medical care. Additional articles that had been published prior to 1995 or in other non-EM journals already known to the authors were also included. A total of 282 articles were identified, and each was categorized into one of the following topics: efficacy of EM for critical care and procedures (31 articles), efficacy of EM for efficiency or cost of care (30 articles), efficacy of EM for public health or preventive medicine (34 articles), efficacy of EM for radiology (11 articles), efficacy of EM for trauma or airway management (27 articles), efficacy of EM for using ultrasound (56 articles), efficacy of EM faculty (34 articles), efficacy of EM residencies (24 articles), and overviews and editorials of EM efficacy and value (35 articles). There is extensive medical literature that supports the efficacy and value for both EM as a medical specialty and for emergency patient care delivered by trained EM physicians.
To describe the case mix, interventions, procedures and management of patients in public emergency departments (ED) in Kenya.
Methods
An observational study over 24 h, of patients who presented to 15 public ED during the 3-month period from 1 October to 31 December 2010. The study was conducted across Kenya in two national referral hospitals, five secondary level hospitals and eight primary level hospitals. All patients presenting alive to the ED during the 24-h study period that were seen by a doctor or clinical officer were included in the study. A data collection form was completed by the primary investigator at the time of the initial ED consultation documenting patient demographics, presenting complaints, investigations ordered, procedures done, initial diagnosis and outcome of ED consultation.
Results
Data on 1887 patient presentations were described. Adults (≥13 years) accounted for the majority (70%) of patients. Two peak age groups, 0–9 and 20–29 years, accounted for 27% and 25% of patients, respectively. Respiratory and trauma presentations each accounted for 21% of presentations, with a wide spread of other presentations. Over half (58%) of the patients were investigated in the department. 385 patients received immediate treatment in the ED before discharge. Fewer than one in three patients admitted or transferred to specialist units received any therapy in the ED.
Conclusions
ED in Kenya provide care to an undifferentiated patient population yet most of the immediate therapy is provided only to patients with minor conditions who are subsequently discharged. Sicker patients have to await transfer to wards or specialist units to start receiving treatment.
Gender differences have been reported both in exposure to and outcome of burn injuries. Whereas the general gender distribution of burns is relatively well known, few studies have examined gender differences in incidence and management of burns for different burn mechanisms in sub-Saharan Africa.
Methods
The study is cross sectional and based on case reports of patients seeking care for a burn injury at Emergency Centres in eight health care facilities in the Western Cape Province, South Africa between June 2012 and May 2013 (n = 1915). Gender specific incidence rates were compiled for age groups 0–4, 5–9, 10–14, 15–19, 20–54 and 55+. Differences in proportions in men and women were examined for AIS, length of stay and disposition. All analyses were stratified by burn mechanism.
Results
Children 0–4 years have the highest incidence of burns with boys and girls relatively equally affected. Gender differences in burn incidence are found in ages 20 years and older. Men 55 years and older have a higher risk compared to women for hot liquid burns whereas men aged 20–54 have a higher risk of fire burns. While no gender differences in children are observed in injury management, adult men are significantly more transferred than women (all burn mechanisms aggregated) while women with both hot liquid and fire burns are treated as outpatients to a higher extent. No gender difference in AIS or length of stay are found among adults.
Conclusions
Even though burn incidence is highest among children, gender differences in burn incidence and management are mainly visible in adults. Results about men being transferred and women treated as outpatients to a higher extent in spite of similar AIS raise the question of hidden gender biases in the healthcare.
Most of the world's trauma-related deaths are borne by developing countries in the pre-hospital setting, with trauma mortality rates over double than those in developed nations and predictions that the situation will get even worse. However, very little is reported about how community members in these settings feel about the violence and emergencies themselves. We aimed to catalogue how community members in one area felt about emergencies and emergency personnel, and how they would psychologically respond to first responder training, a possible intervention to relieve community stress. The Emergency First Aid Responder training course was taught to community members in the Cape Flats region of Cape Town, South Africa. We administered before and after surveys that asked questions about emergencies, emergency personnel, likeliness to help in an emergency (initiative), confidence in helping skills, and in feelings about the training course. The community members felt very negative about emergencies in their area, and most residents feel that emergency personnel are not doing their job adequately. Lack of ability to help is the most prevalent and largest barrier to help during an emergency, and the course was the most effective at addressing this barrier. Violence and emergencies are having a deep, negative impact on the psychology of the Cape Flats' community members. First responder training is one intervention that can provide stress relief to the community, increase the likeliness community members will help each other during an emergency, and increase their confidence while helping. This was true even for those who were not trained voluntarily, and the more a trainee learned in the course the more likely they improved in initiative and confidence. La plupart des décès liés à des traumatismes dans le monde se produisent dans des pays en voie de développement dans le contexte préhospitalier, les taux de mortalité liés au traumatisme étant plus de deux fois supérieurs à ceux des nations développées, la situation devant s'aggraver encore davantage. Cependant, très peu de choses sont rapportées quant à la façon dont les membres des communautés vivent la violence et les urgences dans de tels contextes. Nous avons cherché à cataloguer la façon dont les membres d'une communauté d'une région vivent les urgences et le personnel d'urgence, et la façon dont ils répondraient psychologiquement à une formation pour les premiers intervenants, constituant une intervention possible pour alléger le stress de la communauté. Le programme de formation des premiers intervenants d'urgence a été enseigné aux membres d'une communauté dans la zone des Cape Flats du Cap, en Afrique du Sud. Nous avons organisé des sondages de type avant/après qui s'intéressaient aux urgences, au personnel d'urgence, à la probabilité d'aider dans une situation d'urgence (initiative), à la confiance en les compétences d'aide et aux sentiments sur le programme de formation. Les membres de la communauté étaient très négatifs quant aux urgences dans leur zone, et la plupart des résidents estimaient que le personnel d'urgence ne faisait pas son travail correctement. Le manque de capacité à aider constitue la barrière la plus courante et la plus importante à l'apport d'une aide lors d'une urgence, et le cours s'avérait des plus efficaces pour surmonter cette barrière. La violence et les urgences ont un impact profond et négatif sur la psychologie des membres des communautés des Cape Flats. La formation des premiers intervenants est une intervention pouvant alléger le stress de la communauté, augmenter la probabilité que les membres de la communauté s'entraident lors d'une urgence, et renforcer leur confiance lorsqu'ils apportent de l'aide. Cela s'est vérifié même pour ceux qui n'avaient pas été volontairement formés, et plus un stagiaire apprenait pendant le cours, plus il était probable qu'il gagne en prise d'initiatives et en confiance.
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