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Burnout occurs frequently in emergency medicine (EM) residents and has been shown to have a negative impact on patient care. The specific effects of burnout on patient care are less well understood. This study qualitatively explores how burnout may change the way EM residents provide patient care.Qualitative data were obtained from a sample of 29 EM residents in four semistructured focus groups across four institutions in the United States in early 2019. Transcripts were coded and organized into major patient care themes.Residents described many ways in which feelings of burnout negatively impacted patient care. These detrimental effects most often fit into one of four main themes: reduced motivation to care for patients, poor communication with patients, difficult interactions with health care colleagues, and impaired decision making.According to EM residents, burnout negatively impacts several important aspects of patient care. Resident engagement with clinical care, communication with patients and colleagues, and clinical care may suffer as a result of burnout.

OBJECTIVES: About half of all resident physicians report symptoms of burnout. Burnout negatively influences multiple aspects of their education and training. How burnout may impact residents’ career choices remains unclear. The authors explored the role burnout played in residents’ career decisions. METHODS: This was a qualitative study among a sample of 29 emergency medicine residents from four institutions. Qualitative data were generated through four semistructured focus groups. The authors employed a constructivist approach to thematic analysis. Transcripts were coded and organized into major themes. RESULTS: Five major themes connecting burnout with residents’ career choices emerged: 1) residents’ current burnout and the prevention of future burnout figured prominently in their career considerations, 2) residents aimed to mitigate sources of burnout through their career choices, 3) residents’ view of clinical work as a burden and a burnout contributor spurred the pursuit of other interests, 4) faculty advice and role modeling in relation to burnout shaped residents’ career perspectives, and 5) residents weighed long‐term burnout concerns with short‐term financial needs. CONCLUSION: Burnout played an important role in multiple aspects of residents’ career considerations. Educators, program directors, and organization leaders can focus on identified target areas to address burnout’s influence on residents’ career decisions.

Children present to the emergency department with painful conditions or conditions that require diagnostic or therapeutic procedures every day. As emergency physicians, we need to have the skills to manage our patients’ pain and anxiety in a safe and efficient manner. Appropriately managing pain and anxiety facilitates medical interventions, decreases patients’ suffering, improves patient and parent satisfaction, and improves the quality of care. Conversely, failure to adequately provide analgesia and sedation can have negative consequences for pediatric patients. In the pediatric population, inadequate pain control not only causes immediate harm and fear but can also worsen the reaction to future medical care and potentially affect the child’s long-term psychological well-being. This review provides an overview of pediatric procedural sedation, as well as the pathophysiology and practice. Figures show the sedation continuum with associated physiologic responses, oxyhemoglobin desaturation during apnea for various types of patients, and examples of capnography waveforms in procedural sedation and analgesia (PSA). Tables list potential indications for pediatric PSA in the emergency department, American Society of Anesthesiologists’ classifications, drugs and pharmacokinetics of common agents used in PSA, focused history and physical examination for patients undergoing PSA, SOAPME (Suction, Oxygen, Airway, Pharmacy, Monitors, Equipment) acronym for PSA equipment, and suggested monitoring for PSA pre- and postprocedure. This review contains 3 highly rendered figures, 6 tables, and 41 references. Key words: pediatric analgesia; pediatric pain; pediatric procedural sedation; pediatric sedation; procedural pain relief; procedural sedation and analgesia

The World Health Assembly 2007 Resolution 60.22 tasked the global health community to address the lack of emergency care in low- and middle-income countries. Little progress has yet been made in integrating emergency care into most low- and middle-income-country health systems. At a rural Ugandan district hospital, however, a collaborative between a nongovernmental organization and local and national stakeholders has implemented an innovative emergency care training program. To our knowledge, this is the first description of using task shifting in general hospital-based emergency care through creation of a new nonphysician clinician cadre, the emergency care practitioner. The program provides an example of how emergency care can be practically implemented in low-resource settings in which physician numbers are limited. The Ministry of Health is directing its integration into the national health care system as a component of a larger ongoing effort to develop a tiered emergency care system (out-of-hospital, clinic- and hospital-based provider and physician trainings) in Uganda. This tiered emergency care system is an example of a horizontal health system advancement that offers a potentially attractive solution to meet the mandate of World Health Assembly 60.22 by providing inexpensive educational interventions that can make emergency care truly accessible to the rural and urban communities of low- and middle-income countries.

BACKGROUND: A nonphysician clinician (NPC) training program was started in Uganda in 2009. NPC care was initially supervised by a physician and subsequent care was independent. The mortality of children under 5 (U5) was analyzed to evaluate the impact of transitioning NPC care from physician-supervised to independent care. METHODS: A retrospective review was performed of a quality assurance database including 3-day follow-up for all patients presenting to the emergency department (ED). Mortality rates were calculated and χ2 tests used for significance of proportions. Multiple logistic regression was used to assess independent predictors of mortality. RESULTS: Overall, 68.8% of 4985 U5 patients were admitted and 28.6% were “severely ill.” The overall mortality was significantly lower in physician-supervised versus independent NPC care (2.90% vs 5.04%, P = .05). No significant mortality difference was seen between supervised and unsupervised care (2.17% vs 3.01%, P = .43) for the majority of patients that were not severely ill. Severely ill patients analyzed separately showed a significant mortality difference (4.07% vs 10.3%, P = .01). Logistic regression revealed physician supervision significantly reduced mortality for patients overall (odds ratio = 0.52, P = .03), but not for nonseverely ill patients analyzed separately (odds ratio = 0.73, P = .47). CONCLUSIONS: Though physician supervision reduced mortality for the severely ill subset of patients, physicians are not available full-time in most EDs in Sub-Saharan Africa. Training NPCs in emergency care produced noninferior mortality outcomes for unsupervised NPC care compared with physician-supervised NPC care for the majority of U5 patients.

This study's objectives were to assess administration of a rapidly dissolving transbuccal fentanyl tablet to patients in emergency department (ED) with orthopedic extremity pain. The main end point was time required to achieve a 2-point drop on a 0 to 10 pain scale.In this double-blind trial, subjects received either transbuccal fentanyl, 100 μg, and a swallowed placebo, or a swallowed oxycodone/acetaminophen, 5/325-mg pill, and a nonanalgesic transbuccal comparator. Pain assessment occurred every 5 minutes for an hour, and vital signs were monitored for 2 hours.Transbuccal fentanyl was associated with faster pain relief onset (median, 10 vs 35 minutes; P.0001). Secondary end points (pain relief magnitude, rescue medication rate, subject preference for medication on future visit) favored transbuccal fentanyl. No vital sign abnormalities or significant side effects occurred in the ED or on 100% next-day follow-up.Transbuccal fentanyl shows promise for continued investigation as a means to safely provide rapid and effective pain relief for ED patients.

ObjectivesTo determine the most commonly used resources (provider procedural skills, medications, laboratory studies and imaging) needed to care for patients.SettingA single emergency department (ED) of a district-level hospital in rural Uganda.Participants26 710 patient visits.ResultsProcedures were performed for 65.6% of patients, predominantly intravenous cannulation, wound care, bladder catheterisation and orthopaedic procedures. Medications were administered to 87.6% of patients, most often pain medications, antibiotics, intravenous fluids, antimalarials, nutritional supplements and vaccinations. Laboratory testing was used for 85% of patients, predominantly malaria smears, rapid glucose testing, HIV assays, blood counts, urinalyses and blood type. Radiology testing was performed for 17.3% of patients, including X-rays, point-of-care ultrasound and formal ultrasound.ConclusionThis study describes the skills and resources needed to care for a large prospective cohort of patients seen in a district hospital ED in rural sub-Saharan Africa. It demonstrates that the vast majority of patients were treated with a small formulary of critical medications and limited access to laboratories and imaging, but providers require a broad set of decision-making and procedural skills.

Background Global health experts identify emergency obstetric care (EmOC) as the most important intervention to improve maternal survival in low- and middle-income countries. In Zambia, 1 in 27 women will die of maternal causes, yet the level of availability of EmOC is not known at the provincial level. Aims Our goal was to develop a tool to measure the availability of EmOC in rural Zambia in order to estimate pregnant women’s access to this life-saving intervention. Methods We created an instrument for determining the availability of EmOC based on the supplies and medicines in stock at health facilities as well as the skill level of health workers. We then surveyed a random sample of 35 health centres in the Central Province of Zambia using our novel instrument. Results We graded health centres based on their ability to provide the six basic functions of EmOC: administering parenteral antibiotics, administering parenteral oxytocics, administering parenteral anticonvulsants, performing manual removal of the placenta, removing retained products of conception and performing assisted vaginal delivery. Of the 29 health centres providing delivery care, 65% (19) were graded as level 1 or 2, 28% (8) as level 3 or 4 and 7% (2) as level 5. No health centre received a grade of level 6. Conclusion The availability of EmOC in the Central Province of Zambia is extremely limited; the majority of health centres provide only one or two basic functions of EmOC, and no health centres perform all six functions. Our grading system allows for inter- and intra-country comparisons by providing a systematic process for monitoring access to EmOC in rural, low-income countries similar to Zambia.

Objective To describe the outcomes and curriculum components of an educational programme to train non-physician clinicians working in a rural, Ugandan emergency department in the use of POC ultrasound. Methods The use of point-of-care ultrasound was taught to emergency care providers through lectures, bedsides teaching and hands-on practical sessions. Lectures were tailored to care providers' knowledge base and available therapeutic means. Every ultrasound examination performed by these providers was recorded over 4.5 years. Findings of these examinations were categorised as positive, negative, indeterminate or procedural. Other radiologic studies ordered over this same time period were also recorded. Results A total of 22 639 patients were evaluated in the emergency department by emergency care providers, and 2185 point-of-care ultrasound examinations were performed on 1886 patients. Most commonly used were the focused assessment with sonography in trauma examination (53.3%) and echocardiography (16.4%). Point-of-care ultrasound studies were performed more frequently than radiology department-performed studies. Positive findings were documented in 46% of all examinations. Conclusions We describe a novel curriculum for point-of-care ultrasound education of non-physician emergency practitioners in a resource-limited setting. These non-physician clinicians integrated ultrasound into clinical practice and utilised this imaging modality more frequently than traditional radiology department imaging with a large proportion of positive findings. Objectif Decrire les resultats et le contenu du curriculum d’etude d'un programme educatif pour la formation de cliniciens non medecins dans l'utilisation de l’echographie sur le lieu de soins pour travailler dans un service des urgences en zone rurale en Ouganda. Methodes L'utilisation de l’echographie sur le lieu de soins a ete enseignee aux prestataires de soins d'urgence a travers des conferences a cote des cours et des seances pratiques. Les conferences ont ete adaptees aux connaissances de base des prestataires de soins et des moyens therapeutiques disponibles. Chaque examen echographique effectue par ces prestataires a ete enregistre sur plus de 4,5 annees. Les resultats de ces examens ont ete classes comme positif, negatif, indetermine ou de procedure. D'autres etudes radiologiques realisees au cours de cette meme periode ont egalement ete enregistrees. Resultats 22 639 patients ont ete evalues dans le service d'urgence par les prestataires de soins d'urgence et 2185 echographies sur le lieu des soins ont ete effectuees sur 1886 patients. Plus couramment utilises etaient l’evaluation ciblee avec l’echographie dans l'examen de traumatologie (53,3%) et l’echocardiographie (16,4%). Des etudes sur l’echographie sur le lieu des soins ont ete effectuees plus frequemment que les etudes realisees les services de radiologie. Des resultats positifs ont ete documentes dans 46% de tous les examens. Conclusions Nous decrivons ici un nouveau programme pour l'enseignement de l’echographie sur le point des soins par des prestataires d'urgence non-medecins dans un contexte a ressources limitees. Ces cliniciens non medecins ont integre l’echographie dans la pratique clinique et ont utilise cette methode d'imagerie plus frequemment que l'imagerie traditionnelle du service de radiologie avec une grande proportion de resultats positifs. Objetivo Describir los resultados y componentes curriculares de un programa educativo para formar al personal sanitario no medico en el uso de ultrasonido en el punto de atencion del paciente (PoC) en un departamento de urgencias de una zona rural de Uganda. Metodos Se entreno al personal de servicios de emergencia en el uso de ultrasonido PoC mediante clases magistrales, clases al lado de la cama del paciente y sesiones practicas. Las clases fueron hechas a medida de los conocimientos del personal sanitario y de los medios terapeuticos disponibles. Cada ultrasonografia realizada por este personal se grabo durante 4.5 anos. Los hallazgos de estos examenes se clasificaron como positivo, negativo, indeterminado o procedimental. Tambien se grabaron otros estudios radiologicos realizados durante este mismo periodo de tiempo Resultados Los sanitarios de emergencias evaluaron a 22 639 pacientes en el departamento de urgencias y se realizaron 2185 pruebas de ultrasonido PoC a 1886 pacientes. La evaluacion realizada mas a menudo era la sonografia focalizada para trauma (53.3%) y la ecocardiografia (16.4%). Se realizaron estudios de ultrasonido PoC mas a menudo que pruebas realizadas por el departamento de radiologia. Se documentaron hallazgos positivos en un 46% de todos los examenes. Conclusiones Describimos un nuevo curriculum para educar en el uso de ultrasonido PoC a personal no medico trabajando en urgencias en lugares con recursos limitados. El personal no medico integro el ultrasonido a la practica clinica y utilizo esta modalidad de imagen mas frecuentemente que el departamento de radiologia tradicional, con una gran proporcion de hallazgos positivos.

Background In 2009, a novel task-shifting programme was started in rural Uganda to create access to quality acute and emergency care. Collaborative partners on the project are the Global Emergency Care Collaborative and Karoli Lwanga "Nyakibale" Hospital, Rukungiri, Uganda. One element of this training programme for non-physician emergency-care practitioners (ECPs) is the use point-of-care ultrasound for common emergency applications. As in much of sub-Saharan Africa, radiological diagnostic testing is insufficient in the district hospital's emergency department in which the ECP programme is conducted. X-ray and comprehensive ultrasound is potentially accessible during daytime hours only; however, it is sometimes limited by insufficient availability of materials and trained staff. Methods The use of point-of-care ultrasound has been taught to ECPs through didactic and bedside teaching. As part of the basic curriculum, lectures are given on the use of emergency ultrasound; basic ultrasound physics and safety; extended focused assessment with sonography for trauma (E-FAST); ultrasound-guided nerve blocks; echocardiography; hepatobiliary ultrasound; lung, skin, and soft tissue ultrasound; and obstetric ultrasound. As the programme and skills of the ECPs have advanced, additional ultrasound applications have been added to the curriculum including aorta, renal, Deep vein thrombosis, inferior vena cava, and appendiceal ultrasound. In addition to the lecture component, bedside teaching is a major component. Visiting board-eligible or certified emergency physicians with advanced ultrasound training intermittently proctor exams at scheduled intervals with each emergency care practitioner throughout the course of their training. Findings Through the course of this training programme, non-physician practitioners have integrated the use of bedside ultrasound into their clinical practice of emergency care. Interpretation In a rural resource-limited setting where other diagnostic imaging is insufficient, bedside ultrasound can be taught to non-physician emergency practitioners to diagnose a myriad of emergency disorders. Funding None.

Study objective We determine whether, after a brief training program in procedural sedation, nurses can safely independently administer ketamine sedation in a resource-limited environment. Methods This is an observational case series of consecutive sedations performed in an emergency department in rural Uganda at approximately 5,000 feet above sea level. The data were collected prospectively in a quality assurance database. As part of a larger training program in emergency care at Karoli Lwanga Hospital in rural Uganda, nurses with no sedation experience were trained in procedural sedation with ketamine. All sedations were monitored by a nonphysician research assistant, who recorded ketamine dosing, duration of each procedure, adverse events, and nurse interventions for each adverse event. In accordance with standard definitions in the emergency medicine sedation literature, adverse events were defined a priori and classified as major (death, need for bag-valve-mask ventilation, or unanticipated admission to the hospital) or minor (hypoxia, vomiting, emergence reactions, hypersalivation). The primary statistical analysis was descriptive, with reporting of adverse event rates with 95% confidence intervals (CIs), using the nurse as the unit of analysis. Results There were a total of 191 administrations by 6 nurses during the study period (December 2009 through March 2010). Overall, there was an 18% adverse event rate (95% CI 7% to 30%), which is similar to the rate reported in resource-rich countries. These events included hypoxia (22 cases; 12%), vomiting (9 cases; 5%), and emergence reaction (7 cases; 4%). All adverse events met our a priori defined criteria for minor events, with a 0% incidence of major events (1-sided 97.5% CI with the nurse as unit of analysis 0% to 46%). The procedural success rate was 99%. Sedation was practitioner rated as "excellent" in 91% of cases (95% CI 86% to 94%) and "good" in 9% (95% CI 6% to 14%). Patients reported they would want ketamine for a future procedure in 98% of cases (95% CI 95% to 100%). Conclusion In resource-limited settings, nurse-administered ketamine sedation appears to be safe and effective. A brief procedural sedation training program, coupled with a comprehensive training program in emergency care, can increase access to appropriate and safe sedation for patients in resource-limited settings.

*Division of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, †Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, and ‡Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts Reprint Address: David F. M. Brown, MD, Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Founders 114, Boston, MA 02114

Background Due to the dual critical shortages of acute care and healthcare workers in resource-limited settings, many people suffer or die from conditions that could be easily treated if existing resources were used in a more timely and effective manner. In order to address this preventable morbidity and mortality, a novel emergency midlevel provider training program was developed in rural Uganda. This is the first study that assesses this unique application of a task-shifting model to acute care by evaluating the outcomes of 10,105 patients. Methods Nurses participated in a two-year training program to become midlevel providers called Emergency Care Practitioners at a rural district hospital. This is a retrospective analysis of the Emergency Department’s quality assurance database, including three-day follow-up data. Case fatality rates (CFRs) are reported as the percentage of cases with a specific diagnosis that died within three days of their Emergency Department visit. Findings Overall, three-day mortality was 2.0%. The most common diagnoses of patients who died were malaria (n=60), pneumonia (n=51), malnutrition (n=21), and trauma (n=18). Overall and under-five CFRs were as follows: malaria, 2.0% and 1.9%; pneumonia, 5.5% and 4.1%; and trauma, 1.2% and 1.6%. Malnutrition-related fatality (all cases