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Christopher W Baugh,1 Aaron D Sodickson,2 Sean M Kivlehan,1 Paul C Chen,1 Molly L Perencevich,3 Arun B Jesudian4 1Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA; 2Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA; 3Division of Gastroenterology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA; 4Division of Gastroenterology and Hepatology, Weill Cornell Medicine, New York, NY, USACorrespondence: Christopher W Baugh, Brigham and Women’s Hospital, Department of Emergency Medicine, 75 Francis Street, Neville House 2 nd Floor, Boston, MA, 02115, USA, Tel +1 617-732-8192, Fax +1 617-264-6848, Email cbaugh@bwh.harvard.eduAbstract: Patients with gastrointestinal (GI) bleeding present to the emergency department (ED) with a wide spectrum of illness severity. Among the most critically ill patients, comorbidities and other risk factors, such as liver disease and anticoagulation, can complicate their management. These patients are resource-intensive to stabilize and resuscitate, often requiring the continuous attention of multiple ED staff members along with rapid mobilization of specialty care. At a tertiary care hospital with the ability to provide definitive care for the most critically ill patients with GI bleeding, we introduced a multi-disciplinary team activation pathway to bring together specialists to immediately respond to the ED. We designed a Code GI Bleed pathway to expedite hemodynamic stabilization, diagnostics, source control, and timely disposition out of the ED to the intensive care unit or relevant procedural area of the hospital.Keywords: emergency, gastrointestinal bleeding, endoscopy, gastrointestinal hemorrhage, critical care

Objective: The aim of this study was to evaluate the change in knowledge and skill confidence after implementation of a chemical, biological, radiological, nuclear, and explosive (CBRNE) training course during the Russia-Ukraine War. Methods: Pre/post-test study in the Ukrainian cities of Kyiv, Dnipro, Zaporizhzhia, and Odesa. Fifteen CBRNE courses were conducted over a 3-mo period, August to October 2022. Change in knowledge and skills confidence were evaluated with pre/post-course written exams and practical skill assessments that were observed during the training exercises. Changes were analyzed based on nonparametric Wilcoxon matched-pairs signed-rank testing. Pre/post self-efficacy surveys were analyzed with McNemar’s test for paired data. Course evaluations were conducted with standardized questions which assessed instruction quality, teaching relevance, knowledge gained, and post-course skills confidence. Results: A total of 523 participants registered and completed 1 of the 15 courses. Overall mean pre-course test score: 57.8% (SD 20.7%); mean post-course test score: 81.4% (SD 11.3%); participants with increasing test scores: 90.7%; mean difference in score (95% confidence interval) 23.6% (21.2%-25.9%), P < 0.0001. Pre/post self-efficacy surveys (4-point Likert scale) noted participants recognized signs and symptoms of a CBRNE incident, and necessary skills to manage CBRNE exposures, P < 0.0001. Conclusions: The implementation of this CBRNE course for front-line providers in Ukraine was successful. To our knowledge, it was the first implementation of a field course during the current Russian-Ukraine war. Future research should evaluate knowledge retention and impact of our innovative Train-the-Trainer model. Further iterations should emphasize expanding the quantity of training equipment and practical skill sessions.

Objective To identify, screen, highlight, review, and summarize some of the most rigorously conducted and impactful original research and review articles in global emergency medicine (EM) published in 2020 in the peer-reviewed and gray literature. Methods A broad systematic search of peer-reviewed publications related to global EM indexed on PubMed and in the gray literature was conducted. The titles and abstracts of the articles on this list were screened by members of the Global Emergency Medicine Literature Review team to identify those that met our criteria of original research or review articles in the domains of Disaster and Humanitarian Response, Emergency Care in Resource-Limited Settings, and Emergency Medicine Development. Those articles that met these screening criteria were then scored using one of three scoring templates appropriate to the article type. Those articles that scored in the top 5% then underwent in-depth narrative summarization. Results The 2020 GEMLR search initially identified 35,970 articles, more than 50% more than last year's search. From these, 364 were scored based on their full text. Nearly three-fourths of the scored articles constituted original research, of which nearly three-fourths employed quantitative research methods. Nearly 10% of the articles identified this year were directly related to COVID-19. Research involving Emergency Care in Resource-Limited Settings again constituted most of the articles in this year's review, accounting for more than 60% of the literature scored. A total of 20 articles underwent in-depth narrative critiques. Conclusions The number of studies relevant to global EM identified by our search was very similar to last year. Revisions to our methodology to identify a broader range of research were successful in identifying more qualitative research and studies related to Disaster and Humanitarian Response. The number of COVID-19-related articles is likely to continue to increase in subsequent years.

Severe acute respiratory infections (SARIs) remain a leading cause of death globally, particularly in low- and middle-income countries (LMICs). Early intervention is critical, considering the potential for rapid decompensation in patients with SARIs. We aimed to evaluate the impact of acute and emergency care interventions on improving clinical outcomes in patients10 years old with SARIs in LMICs.A systematic literature search was performed in PubMed, Global Health, and Global Index Medicus databases to identify peer-reviewed studies containing SARI, LMICs, and emergency care interventions. Studies published prior to November 2020 focusing on patients10 years old were included. A narrative synthesis was performed due to the heterogeneity of identified articles. Risk of bias was assessed using the Risk of Bias 2 and Risk of Bias In Non-Randomized Studies of Interventions tools.20 223 studies were screened and 58 met the inclusion criteria. Thirty-four studies focused on coronavirus-2019 (COVID-19), 15 on pneumonia, seven on influenza, one study on severe acute respiratory syndrome, and one on undifferentiated SARI. Few COVID-19 studies found a benefit of the tested intervention on clinical status, mortality, or hospital length-of-stay. Little to no benefit was found for azithromycin, convalescent plasma, or zinc, and potential harm was found for hydroxychloroquine/chloroquine. There was mixed evidence for immunomodulators, traditional Chinese medicine, and corticosteroids among COVID-19 studies, with notable confounding due to a lack of consistency of control group treatments. Neuraminidase inhibitor antivirals for influenza had the highest quality of evidence for shortening symptom duration and decreasing disease severity.We found few interventions for SARIs in LMICs with have high-quality evidence for improving clinical outcomes. None of the included studies evaluated non-pharmacologic interventions or were conducted in low-income countries. Further studies evaluating the impact of antivirals, immunomodulators, corticosteroids, and non-pharmacologic interventions for SARIs in LMICs are urgently needed.PROSPERO registration number: CRD42020216117.

The objective was to identify the most important and impactful peer-reviewed global emergency medicine (GEM) articles published in 2021. The top articles are summarized in brief narratives and accompanied by a comprehensive list of all identified articles that address the topic during the year to serve as a reference for clinicians, researchers, and policy makers.A systematic PubMed search was carried out to identify all GEM articles published in 2021. Title and abstract screening was performed by trained reviewers and editors to identify articles in one of three categories based on predefined criteria: disaster and humanitarian response (DHR), emergency care in resource-limited settings (ECRLS), and emergency medicine development (EMD). Included articles were each scored by two reviewers using established rubrics for original (OR) and review (RE) articles. The top 5% of articles overall and the top 5% of articles from each category (DHR, ECRLS, EMD, OR, and RE) were included for narrative summary.The 2021 search identified 44,839 articles, of which 444 articles screened in for scoring, 25% and 22% increases from 2020, respectively. After removal of duplicates, 23 articles were included for narrative summary. ECRLS constituted the largest category (n = 16, 70%), followed by EMD (n = 4, 17%) and DHR (n = 3, 13%). The majority of top articles were OR (n = 14, 61%) compared to RE (n = 9, 39%).The GEM peer-reviewed literature continued to grow at a fast rate in 2021, reflecting the continued expansion and maturation of this subspecialty of emergency medicine. Few high-quality articles focused on DHR and EMD, suggesting a need for further efforts in those fields. Future efforts should focus on improving the diversity of GEM research and equitable representation.

Resource limited settings have an ongoing need for access to quality emergency care. The World Health Organization - International Committee of the Red Cross Basic Emergency Care (BEC) course is one mechanism to address this need. Training of BEC trainers has been challenging due to barriers including cost, travel logistics, scheduling, and more recently, social distancing regulations related to the coronavirus pandemic.We seek to determine if an online virtual format is an effective way to train additional trainers while overcoming these barriers.The BEC Training-of-Trainers (ToT) course was adapted to a virtual format and delivered entirely online. Participants were assessed with a multiple choice pre- and post-test and completed a course feedback form upon completion. Results from the virtual course were then compared to the results from an in-person ToT course.The in-person course pre- and post-tests were completed by 121 participants with a pre-test mean of 87% (range 60-100%) and a post-test mean of 95% (range: 75-100; p0.05). Virtual course pre- and post-tests by 27 participants were analyzed with a pre-test mean of 89% (range 75-100%) and a post-test mean of 96% (range: 79-100; p0.05). No difference in test improvements between the courses was detected (z = -0.485; p = 0.627). The course feedback was completed by 93 in-person participants and 28 virtual participants. Feedback survey responses were similar for all questions except for course length, with in-person participant responses trending towards the course being too long.A virtual format BEC ToT course is effective, feasible, and acceptable. When compared to an in-person course, no difference was detected in nearly all metrics for the virtual format. Utilizing this format for future courses can assist in scaling both the BEC ToT and, by extension, the BEC course globally, particularly in regions facing barriers to in-person training.

Objective The annual systematic search of the peer-reviewed and gray literature relevant to global emergency medicine (EM) was conducted by the Global Emergency Medicine Literature Review (GEMLR) to screen, evaluate, and review the most rigorously conducted and relevant research in global EM published in 2019. Methods After a broad search of PubMed and websites of organizations publishing relevant gray literature, all articles that were deemed relevant to the fields of disaster and humanitarian response, emergency care in resource-limited settings, and EM development by at least one reviewer, an editor, and the managing editors were then scored by two different reviewers using a 20-point scoring template relevant to either original research (OR) or review (RE) articles. This scoring system rates articles on their clarity, research design, ethics, importance to global EM, and breadth of impact. Articles that then scored in the top 5% were then critiqued in depth. Results A total of 23,321 article titles and abstracts were screened by 22 reviewers with a wide swath of clinical and research experience in global EM. From these, a total of 356 articles underwent full-text review and scoring on the 20-point scale; 26% were categorized as disaster and humanitarian response, 58% as emergency care in resource-limited settings, and 15% as EM development. Of these 356 articles, 276 (77.5%) were OR articles and 80 (22.5%) were RE articles. The 16 articles that scored in the top 5% (>17.5 of 20 points) received full in-depth narrative summaries. Conclusions In 2019, the overall number of studies relevant to global EM that were identified by our search decreased from the prior year, but more high-scoring articles related to the development of EM clinical practice and as a specialty in resource-constrained settings were identified.

This White Paper has been formally accepted for support by the International Federation for Emergency Medicine (IFEM) and by the World Federation of Intensive and Critical Care (WFICC), put forth by a multi-specialty group of intensivists and emergency medicine providers from low- and low-middle-income countries (LMICs) and high-income countries (HiCs) with the aim of 1) defining the current state of caring for the critically ill in low-resource settings (LRS) within LMICs and 2) highlighting policy options and recommendations for improving the system-level delivery of early critical care services in LRS. LMICs have a high burden of critical illness and worse patient outcomes than HICs, hence, the focus of this White Paper is on the care of critically ill patients in the early stages of presentation in LMIC settings. In such settings, the provision of early critical care is challenged by a fragmented health system, costs, a health care workforce with limited training, and competing healthcare priorities. Early critical care services are defined as the early interventions that support vital organ function during the initial care provided to the critically ill patient—these interventions can be performed at any point of patient contact and can be delivered across diverse settings in the healthcare system and do not necessitate specialty personnel. Currently, a single “best” care delivery model likely does not exist in LMICs given the heterogeneity in local context; therefore, objective comparisons of quality, efficiency, and cost-effectiveness between varying models are difficult to establish. While limited, there is data to suggest that caring for the critically ill may be cost effective in LMICs, contrary to a widely held belief. Drawing from locally available resources and context, strengthening early critical care services in LRS will require a multi-faceted approach, including three core pillars: education, research, and policy. Education initiatives for physicians, nurses, and allied health staff that focus on protocolized emergency response training can bridge the workforce gap in the short-term; however, each country’s current human resources must be evaluated to decide on the duration of training, who should be trained, and using what curriculum. Understanding the burden of critical Illness, best practices for resuscitation, and appropriate quality metrics for different early critical care services implementation models in LMICs are reliant upon strengthening the regional research capacity, therefore, standard documentation systems should be implemented to allow for registry use and quality improvement. Policy efforts at a local, national and international level to strengthen early critical care services should focus on funding the building blocks of early critical care services systems and promoting the right to access early critical care regardless of the patient’s geographic or financial barriers. Additionally, national and local policies describing ethical dilemmas involving the withdrawal of life-sustaining care should be developed with broad stakeholder representation based on local cultural beliefs as well as the optimization of limited resources.

Objectives The Global Emergency Medicine Literature Review (GEMLR) conducts a systematic annual search of peer-reviewed and gray literature relevant to global emergency medicine (EM) to identify, review, and disseminate the most rigorously conducted and widely relevant research in global EM. Methods An electronic search of PubMed, a comprehensive retrieval of articles from specific journals, and search of the gray literature were conducted. Title and abstracts retrieved by these searches were screened by a total of 22 reviewers based on their relevance to the field of global EM, across the domains of disaster and humanitarian response (DHR), emergency care in resource-limited settings (ECRLS), and emergency medicine development (EMD). All articles that were deemed relevant by at least one reviewer, their editor, and the managing editor underwent formal scoring of overall methodologic quality and importance to global EM. Two independent reviewers scored all articles; editors provided a third score in cases of widely discrepant scores. Results A total of 19,102 articles were identified by the searches and, after screening and removal of duplicates, a total of 517 articles underwent full review. Twenty-five percent were categorized as DHR, 61% as ECRLS, and 15% as EMD. Inter-rater reliability testing between the reviewers revealed a Cohen's kappa score of 0.213 when considering the complete score or 0.426 when excluding the more subjective half of the score. A total of 25 articles scored higher than 17.5 of 20; these were selected for a full summary and critique. Conclusions In 2018, the total number of articles relevant to global EM that were identified by our search continued to increase. Studies and reviews focusing on pediatric infections, several new and traditionally underrepresented topics, and landscape reviews that may help guide clinical care in new settings represented the majority of top-scoring articles. A shortage of articles related to the development of EM as a specialty was identified.

There is an ongoing and established need for humanitarian training and professionalization. The coronavirus disease 2019 (COVID-19) pandemic disrupted training programs designed to accomplish this goal, including the Humanitarian Response Intensive Course, which includes a 3-d immersive simulation to prepare humanitarian workers for future field work. To provide program continuity, the 3-d simulation was quickly adapted to a virtual format using a combination of video conferencing, short messaging service, and cloud-based file storage software. Participants were geographically dispersed and participated virtually. Learning objectives were preserved, while some components not amenable to a virtual format were removed.A virtual humanitarian training simulation is a feasible, acceptable, and affordable alternative to an in-person simulation. Participants were engaged and experienced minimal technological disruptions. The majority of students believed the format met or exceeded expectations. However, feedback also emphasized the importance of providing sufficient time for team collaboration and deliverable preparation in the simulation schedule. The virtual format was more affordable than the traditional in-person simulation, and diverse expert faculty who could not have attended in-person were able to participate. This format could be used to overcome other barriers to in-person simulation training, including geographic, financial, time, or security.

Background: Prehospital care is a key component of an emergency care system. Prehospital providers initiate patient care in the field and transition it to the emergency department. Emergency Medicine (EM) specialist training programs are growing rapidly in low- and middle-income countries (LMICs), and future emergency physicians will oversee emergency care systems. Despite this, no standardized prehospital care curriculum exists for physicians in these settings. This report describes the development of a prehospital rotation for an EM residency program in Central Haiti. Methods: Using a conceptual framework, existing prehospital curricula from high-income countries (HICs) were reviewed and adapted to the Haitian context. Didactics covering prehospital care from LMICs were also reviewed and adapted. Regional stakeholders were identified and engaged in the curriculum development. Results: A one-week long, 40-hour curriculum was developed which included didactic, clinical, evaluation, and assessment components. All senior residents completed the rotation in the first year. Feedback was positive from residents, field sites, and students. Conclusions: A standardized prehospital rotation for EM residents in Haiti was successfully implemented and well-received. This model of adaptation and local engagement can be applied to other residency programs in low-income countries to increase physician engagement in prehospital care.

ObjectiveEvaluate the change in participant emergency care knowledge and skill confidence after implementation of the WHO-International Committee of the Red Cross (ICRC) Basic Emergency Care (BEC) course.DesignPretest/post-test quasi-experimental study.SettingMechnikov Hospital in Dnipro, Ukraine.ParticipantsSeventy-nine participants engaged in the course, of whom 50 (63.3%) completed all assessment tools. The course was open to healthcare providers of any level who assess and treat emergency conditions as part of their practice. The most common participant profession was resident physician (24%), followed by health educator (18%) and prehospital provider (14%).InterventionsThe 5-day WHO-ICRC BEC course.Primary and secondary outcome measuresChange in pre-course and post-course knowledge and skill confidence assessments. Open-ended written feedback was collected upon course completion and analysed for common themes.ResultsParticipant knowledge assessment scores improved from 19 (IQR 15–20) to 22 (IQR 19–23) on a 25-point scale (pConclusionsThis first implementation of the WHO-ICRC BEC course for front-line healthcare providers in Ukraine was successful and well received by participants. This is also the first report of a BEC implementation outside of Africa and suggests that the course is also effective in the European context, particularly in humanitarian crisis and conflict settings. Future research should evaluate long-term knowledge retention and the impact on patient outcomes. Further iterations should emphasise local language translation and consider expanding clinical skills sessions.

Introduction Emergency medicine (EM) was recognized as a specialty in Ecuador in 1993. Currently, there are two four-year EM residency programs and an estimated 300 residency-trained emergency physicians countrywide. This study describes the current challenges in EM in Ecuador. Methods We conducted 25 semi-structured, in-person interviews with residency-trained emergency physicians, general practitioners, public health specialists, prehospital personnel, and physicians from other specialties. The interviewer asked about challenges in the areas of emergency care, working conditions of emergency physicians, EM residency education, EM leadership, and prehospital care. We analyzed data for challenges and registered the number of interviewees who mentioned each challenge. Results Interviewees worked in the three largest cities in the country: Quito (60%); Guayaquil (20%); and Cuenca (20%). Interviewees included 16 (64%) residency-trained emergency physicians; six (24%) residency-trained physicians from other specialties working in or closely associated with the emergency department (ED); one (4%) general practitioner working in the ED; one (4%) specialist in disasters; and one (4%) paramedic. Shortage of medical supplies, need for better medico-legal protection, lack of EM residencies outside of Quito, and desire for more bedside teaching were the challenges mentioned with the highest frequency (each 44%). The next most frequently mentioned challenges (each 38%) were the need for better access to ultrasound equipment and the low presence of EM outside the capital city. Other challenges mentioned included the low demand for emergency physicians in private institutions, the lack of differential pay for night and weekends, need for more training in administration and leadership, need for a more effective EM national society, and lack of resources and experience in EM research. Conclusion Emergency medicine has a three-decade history in Ecuador, reaching important milestones such as the establishment of two EM residencies and a national EM society. Challenges remain in medical care, working conditions, residency education, leadership, and prehospital care. Stronger collaboration and advocacy among emergency physicians can help strengthen the specialty and improve emergency care.

To date, the practice of global emergency medicine (GEM) has involved being "on the ground" supporting in-country training of local learners, conducting research, and providing clinical care. This face-to-face interaction has been understood as critically important for developing partnerships and building trust. The COVID-19 pandemic has brought significant uncertainty worldwide, including international travel restrictions of indeterminate permanence. Following the 2020 Society for Academic Emergency Medicine meeting, the Global Emergency Medicine Academy (GEMA) sought to enhance collective understanding of best practices in GEM training with a focus on multidirectional education and remote collaboration in the setting of COVID-19. GEMA members led an initiative to outline thematic areas deemed most pertinent to the continued implementation of impactful GEM programming within the physical and technologic confines of a pandemic. Eighteen GEM practitioners were divided into four workgroups to focus on the following themes: advances in technology, valuation, climate impacts, skill translation, research/scholastic projects, and future challenges. Several opportunities were identified: broadened availability of technology such as video conferencing, Internet, and smartphones; online learning; reduced costs of cloud storage and printing; reduced carbon footprint; and strengthened local leadership. Skills and knowledge bases of GEM practitioners, including practicing in resource-poor settings and allocation of scarce resources, are translatable domestically. The COVID-19 pandemic has accelerated a paradigm shift in the practice of GEM, identifying a previously underrecognized potential to both strengthen partnerships and increase accessibility. This time of change has provided an opportunity to enhance multidirectional education and remote collaboration to improve global health equity.

BackgroundThere is a pressing need for emergency care (EC) training in low-resource settings. We assessed the feasibility and acceptability of training frontline healthcare providers in emergency care with the World Health Organization (WHO)-International Committee of the Red Cross (ICRC) Basic Emergency Care (BEC) Course using a training-of-trainers (ToT) model with local providers.MethodsQuasiexperimental pretest and post-test study of an educational intervention at four first-level district hospitals in Tanzania and Uganda conducted in March and April of 2017. A 2-day ToT course was held in both Tanzania and Uganda. These were immediately followed by a 5-day BEC Course, taught by the newly trained trainers, at two hospitals in each country. Both prior to and immediately following each training, participants took assessments on EC knowledge and rated their confidence level in using a variety of EC skills to treat patients. Qualitative feedback from participants was collected and summarised.ResultsFifty-nine participants completed the four BEC Courses. All participants were current healthcare workers at the selected hospitals. An additional 10 participants completed a ToT course. EC knowledge scores were significantly higher for participants immediately following the training compared with their scores just prior to the training when assessed across all study sites (Z=6.23, pConclusionsImplementation of the WHO-ICRC BEC Course by locally trained providers was feasible, acceptable and well received at four sites in East Africa. Participation in the training course was associated with a significant increase in EC knowledge and confidence at all four study sites. The BEC is a low-cost intervention that can improve EC knowledge and skill confidence across provider cadres.

Introduction:Countries most affected by disasters are often those with limited local capacity to respond. When local capacity is overwhelmed, international humanitarian response often provides needs-based emergency response. Despite global progress in education and the development of international humanitarian response standards, access to training and integration of local actors in response mechanisms remains limited. In May 2017, the Haiti Humanitarian Response Course (HHRC) was implemented in Mirebalais, Haiti to increase local capacity and allow for effective future engagement with international humanitarian actors in a country prone to disasters.Report:In collaboration with the Hôpital Universitaire de Mirebalais’ (HUM; Mirebalais, Haiti) Department of Medical Education and Emergency Medicine (EM) residency program, four physicians from the Division of Global Emergency Care and Humanitarian Studies at Brigham and Women’s Hospital (Boston, Massachusetts USA) facilitated the course, which included 53 local physicians and staff. Following 15 hours of online pre-course preparation, through didactics and practical small-group exercises, the course focused on key components of international humanitarian response, minimum standards for effective response, and the roles of key response players. The course was free to participants and taught in English and French.Discussion:The HHRC reduced the barriers often faced by local actors who seek training in international humanitarian response by offering free training in their own community. It presents a novel approach to narrow critical gaps in training local populations in international humanitarian response, especially in environments prone to crises and disasters. This approach can help local responders better access international humanitarian response mechanisms when the local response capacity is exhausted or overwhelmed.Conclusion:The HHRC demonstrates a potential new model for humanitarian and disaster training and offers a model for similar programs in other disaster-prone countries. Ultimately, local capacity building could lead to more efficient resource utilization, improved knowledge sharing, and better disaster response.

The intersection of digital health platforms and refugee health in the context of the novel 2019 coronavirus disease (COVID-19) has not yet been explored. We discuss the ability of a novel mobile health (mhealth) platform to be effectively adapted to improve health access for vulnerable displaced populations. In a preliminary analysis of 200 Syrian refugee women, we found positive user feedback and uptake of an mhealth application to increase access to preventive maternal and child health services for Syrian refugees under temporary protection in Turkey. Rapid adaptation of this application was successfully implemented during a global pandemic state to perform symptomatic assessment, disseminate health education, and bolster national prevention efforts. We propose that mhealth interventions can provide an innovative, cost-effective, and user-friendly approach to access the dynamic needs of refugees and other displaced populations, particularly during an emerging infectious disease outbreak.

Disasters can dismantle the lives of entire populations in unimaginable ways. Minimizing the impact of these disasters, and helping people to recover from their aftermath, are major areas of concern in the global public health field. Increasingly so, largely because of innovations, decreasing cost, and increasing accessibility, is the ability of technology to both mitigate and assist with the response to disasters. Some of the specific methods by which technology can assist in the field of disaster response investigated in this chapter include virtual reality simulations, modeling and simulation of disasters, the use of mobile technology and phones for civilians, social media, early warning systems, mapping, and information dissemination. The next steps necessary to optimize the use of technology in disaster preparedness, as well as a specific case study outlining the workflow in the face of a disaster, are also included.

Background: There is a pressing need for emergency care training in low-resource settings. We assessed the feasibility and acceptability of training front-line health care providers in emergency care with the WHO-ICRC Basic Emergency Care Course using a training-of-trainers model with local providers.Methods: Observational study of an educational intervention at four first level district hospitals in Tanzania and Uganda. A two-day training-of-trainers course was held in both Tanzania and Uganda. These were immediately followed by a 5-day BEC course, taught by the newly trained trainers, at two district level hospitals in each country. Difference between pre- and post-basic emergency care knowledge assessments and difference in pre- and post-emergency care skill confidence scores were assessed. Secondary outcomes include qualitative feedback on the training from participants and trainers. Results: 59 participants completed the BEC courses. All participants were current health care workers in the selected hospitals. An additional 10 participants completed a training-of-trainers course. Knowledge assessment scores improved significantly at all four sites with an overall 20.7 point (95%CI: 16.8 to 24.6; p Conclusions: Implementation of WHO-ICRC BEC Course by locally trained providers was feasible, acceptable, and well-received at four sites in East Africa. Knowledge assessment scores and trainee confidence increased significantly at all sites. The BEC is a low-cost intervention that can improve knowledge and skill confidence across provider cadres.

Objectives The Global Emergency Medicine Literature Review (GEMLR) conducts an annual search of peer-reviewed and gray literature relevant to global emergency medicine (EM) to identify, review, and disseminate the most important new research in this field to a global audience of academics and clinical practitioners. Methods This year, 17,722 articles written in three languages were identified by our electronic search. These articles were distributed among 20 reviewers for initial screening based on their relevance to the field of global EM. Another two reviewers searched the gray literature, yielding an additional 11 articles. All articles that were deemed appropriate by at least one reviewer and approved by their editor underwent formal scoring of overall quality and importance. Two independent reviewers scored all articles. Results A total of 848 articles met our inclusion criteria and underwent full review. Sixty-three percent were categorized as emergency care in resource-limited settings, 23% as disaster and humanitarian response, and 14% as EM development. Twenty-one articles received scores of 18.5 or higher out of a maximum score 20 and were selected for formal summary and critique. Inter-rater reliability testing between reviewers revealed a Cohen's kappa of 0.344. Conclusions In 2017, the total number of articles identified by our search continued to increase. Studies and reviews with a focus on infectious diseases, pediatrics, and trauma represented the majority of top-scoring articles.

Emergency Medical Service (EMS) providers are tasked with rapid evaluation, stabilization, recognition, and transport of acute stroke patients. Although prehospital stroke scales were developed to assist with stroke recognition, unrecognized challenges exist in the prehospital setting that hinder accurate assessment of stroke. The goal of this qualitative study was to systematically understand the challenges and barriers faced by paramedics in recognizing stroke presentations in the field.Paramedics from 12 EMS agencies serving a mix of rural, suburban, and urban communities in the State of California participated in five focus group discussions. Group size ranged from 3-8, with a total of 28 participants. Demographics of the participants were collected and focus group recordings were transcribed verbatim. Transcripts were subjected to deductive and inductive coding, which identified recurrent and divergent themes.Strong consensus existed around constraints to prehospital stroke recognition; participants cited the diversity of stroke presentations, linguistic diversity, and exam confounded by alcohol and or drug use as barriers to initial evaluation. Also, lack of educational feedback from hospital staff and physicians and continuing medical education on stroke were reported as major deterrents to enhancing their diagnostic acumen. Across groups, participants reported attempting to foster relationships with hospital personnel to augment their educational needs, but this was easier for rural than urban providers.While challenges to stroke recognition in the field were slightly different for rural and urban EMS, participants concurred that timely, systematic feedback on individual patients and case-based training would strengthen early stroke recognition skills.

Objectives Malnutrition contributes to paediatric morbidity and mortality in disasters and complex emergencies, but summary data describing specific nutritional interventions in these settings are lacking. This systematic review aimed to characterise such interventions and their effects on paediatric mortality, anthropometric measures and serum markers of nutrition. Methods A systematic search of OVID MEDLINE, Cochrane Library and relevant grey literature was conducted. We included all randomised controlled trials and observational controlled studies evaluating effectiveness of nutritional intervention(s) on defined health outcomes in children and adolescents (0–18 years) within a disaster or complex emergency. We extracted study characteristics, interventions and outcomes data. Study quality was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. Results A total of 31 studies met inclusion criteria. Most were conducted in Africa (17), during periods of conflict or hunger gaps (14), and evaluated micronutrient supplementation (14) or selective feeding (10). Overall study quality was low, with only two high and four moderate quality studies. High- and medium-quality studies demonstrated positive impact of fortified spreads, ready-to-use therapeutic foods, micronutrient supplementation, and food and cash transfers. Conclusion In disasters and complex emergencies, high variability and low quality of controlled studies on paediatric malnutrition limit meaningful data aggregation. If existing research gaps are to be addressed, the inherent unpredictability of humanitarian emergencies and ethical considerations regarding controls may warrant a paradigm shift in what constitutes adequate methods. Periodic hunger gaps may offer a generalisable opportunity for robust trials, but consensus on meaningful nutritional endpoints is needed.

A 60-year-old man presents to the emergency department (ED) by EMS with a report of sudden collapse while running a road race. It is a hot summer day, and he was at mile 5 of a 10 K race when he suddenly collapsed. He was helped up by bystanders after a report of roughly 1 min of unconsciousness. He has scrapes on his knees and elbows from the fall to pavement but is only complaining of fatigue. He is awake and alert, with mild tachycardia, a normal blood pressure, and a normal neurological exam. His respiratory rate is normal and he is afebrile. His skin is pale and warm, with some mild sweat. He reports that he has a history of hypertension and non-insulin-dependent diabetes. He takes metformin for the latter, but cannot recall his antihypertensive medication name. EMS has started a peripheral IV en route and given him 500 cm3 of normal saline. They report that a 12 lead ECG showed sinus tachycardia without any features concerning for arrhythmia or ischemia.

Introduction: The emergency medical services (EMS) system plays a crucial role in the chain of survival for acute myocardial infarction (AMI) and stroke. While regional studies have shown underutilization of the 911 system for these time-sensitive conditions, national trends have not been studied. Our objective was to describe the national prevalence of EMS use for AMI and stroke, examine trends over a six-year period, and identify patient factors that may contribute to utilization. Methods: Using the National Hospital Ambulatory Medical Care Survey-ED (NHAMCS) dataset from 2003-2009, we looked at patients with a discharge diagnosis of AMI or stroke who arrived to the emergency department (ED) by ambulance. We used a survey-weighted χ2 test for trend and logistic regression analysis. Results: In the study, there were 442 actual AMI patients and 220 (49.8%) presented via EMS. There were 1,324 actual stroke patients and 666 (50.3%) presented via EMS. There was no significant change in EMS usage for AMI or stroke over the six-year period. Factors independently associated with EMS use for AMI and stroke included age (OR 1.21; 95% CI 1.12-1.31), Non-Hispanic black race (OR 1.72; 95% CI 1.16-2.29), and nursing home residence (OR 11.50; 95% CI 6.19-21.36). Conclusion: In a nationally representative sample of ED visits from 20003-2009, there were no trends of increasing EMS use for AMI and stroke. Efforts to improve access to care could focus on patient groups that underutilize the EMS system for such conditions. [West J Emerg Med. 2014;15(7):–0.]

Evidence-based medicine will continually change the paradigm in which emergency medicine is practiced. Fifteen years ago tourniquets were a last resort and often considered a guaranteed way to lose a limb; today they are a gold standard in hemorrhage control. Believing in, and having practiced, medicine we later learn to be false doesn't make someone a bad provider, nor does it make them wrong. It simply means emergency medicine and EMS will continue to develop as a profession, and our body of evidence will continue to grow as we learn more about prehospital care. As we prepare to retire MAST, backboards and lidocaine, and realize the golden hour as a concept rather than a definitive 60 minutes, it's important to keep a critical eye out for the next intervention that truly will help patients during their prehospital care.

Managing the airway does not mean intubation, it means managing the airway. Allowing a patient to breathe on their own with appropriate positioning, bag-valve ventilation and blind insertion devices are all airway management options. The surgical cricothyrotomy is a rare and life-saving procedure when managing patients who are in a "can't intubate, can't ventilate" situation. These patients will die without aggressive and rapid intervention. While not all surgical cricothyrotomies provide a definitive airway, the needle cricothyrotomy is an ineffective means for ventilation and its use is discouraged. Understand the techniques used in your program and that are within your scope of practice as an EMS provider. Provide your patient the best opportunity for survival by knowing your program's surgical airway procedure thoroughly, and practice it regularly.

Aortic dissections and aneurysms are seen with low frequency and have high risk for deterioration during prehospital care. It is essential to include both dissections and aneurysms in your differential diagnoses whenever evaluating patients with chest or abdominal complaints. Often a good history is the best indication of one of these grave vascular emergencies. Consider thoracic aortic dissection in your differential diagnosis for any patient who complains of chest pain and aortic aneurysm in patients who have any sort of abdominal discomfort or syncope with an unknown etiology. When either is suspected transport rapidly to a facility with cardiothoracic and vascular surgery capability, and provide care that prepares you to manage the patient quickly should a rupture occur.

Time-sensitive emergencies require early recognition and rapid transport to a facility properly equipped to manage the patient's needs. When managing STEMI, cardiac arrest, suspected stroke, trauma or a severe sepsis patient, use your resources smartly. Manage the patient using all of your capabilities on scene and know the destination best prepared to manage the patient upon ED arrival. When it makes sense to extend transport time to take a patient to a proper facility, it is OK to do so. Considering air medical transport for patients as ground transports exceed 30 minutes is reasonable as long as the flight team provides transport more rapidly or brings additional care that will improve patient outcomes.

Reducing back injuries requires a holistic approach and investment by all interested parties, from front-line staff to leadership and supporting agencies. As a provider, take the time to ensure you are lifting and moving equipment and patients in a manner that protects both the patient and you.

Point-of-care testing is a rapidly evolving yet complex field. As your POCT program grows, take the time to understand the regulations, as they are important to ensuring patient safety. The regualtions established CLIA are designed to ensure consistent and reliable laboratory results that can accurately impact patient care. When beginning your look into POCY, first identify what labs can directly impact your patient care, then look for a device that meets your needs.