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Introduction: Traumatic injuries disproportionately affect populations in low and middle-income countries (LMIC) where head injuries predominate. The Rwandan Ministry of Health (MOH) has dramatically improved access to emergency services by rebuilding its health infrastructure. The MOH has strengthened the nation’s acute emergency response by renovating emergency departments (ED), developing the field of emergency medicine as a specialty, and establishing a prehospital care service: Service d’Aide Medicale Urgente (SAMU). Despite the prevalence of traumatic injury in LMIC and the evolving emergency service in Rwanda, data regarding head trauma epidemiology is lacking. Methods: We conducted this retrospective cohort study at the University Teaching Hospital of Kigali (UTH-K) and used a linked prehospital database to investigate the demographics, mechanism, and degree of acute medical interventions amongst prehospital patients with head injury. Results: Of the 2,426 patients transported by SAMU during the study period, 1,669 were found to have traumatic injuries. Data from 945 prehospital patients were accrued, with 534 (56.5%) of these patients diagnosed with a head injury. The median age was 30 years, with most patients being male (80.3%). Motor vehicle collisions accounted for almost 78% of all head injuries. One in six head injuries were due to a pedestrian struck by a vehicle. Emergency department interventions included intubations (6.7%), intravenous fluids (2.4%), and oxygen administration (4.9%). Alcohol use was not evaluated or could not be confirmed in 81.3% of head injury cases. The median length of stay (LOS) in the ED was two days (interquartile range: 1,3). A total of 184 patients were admitted, with 13% requiring craniotomies; their median in-hospital care duration was 13 days. Conclusion: In this cohort of Rwandan trauma patients, head injury was most prevalent amongst males and pedestrians. Alcohol use was not evaluated in the majority of patients. These traumatic patterns were predominantly due to road traffic injury, suggesting that interventions addressing the prevention of this mechanism, and treatment of head injury, may be beneficial in the Rwandan setting.

Background: Emergency care is an essential part of a health system. Ecuador has recognized emergency medicine as a specialty and has two emergency medicine residency training programs. However, little has been published about emergency department characteristics and capabilities in Ecuador. Objective: We described the characteristics and capabilities of emergency departments (EDs) in Quito, Ecuador, in 2017, using the National Emergency Department Inventory (NEDI) survey. Methods: The 23-item survey included questions pertaining to ED characteristics, including: visit volume, physical and administrative structure, clinical capabilities, technological resources, and consult personnel availability. This study included all EDs in Quito operating 24 hours/day, 7 days/week, and serving all patients seeking care. One representative from each ED was asked to complete the survey based on calendar year 2017. Findings: Thirty EDs met the inclusion criteria, and 26 completed the survey (87% response). The median number of ED beds was 17 (range 2–61). Median annual visit volume was 22,580 (range 1,680 to 129,676). All but two EDs provided care for both children and adults. Cardiac monitors were available in 88% of EDs, CT scanners in 68%, and rooms for respiratory isolation in 31%. Most EDs could manage patients with general medicine (92%), general surgery (92%), and gynecology (88%) emergencies 24/7. Fewer were able to provide hand surgery (45%) and dental (28%) care 24/7. Typical length of stay was 1–6 hours in 65% and >6 hours in 31% of EDs. Half of EDs reported operating at full capacity and 27% reported operating over their capacity. When compared to private EDs, government EDs (public and social security) had a higher mean number of visits per year (50,090 government vs. 13,968 private, p < 0.001), higher mean number of ED beds (36 government vs. 9 private, p = 0.002), and higher length of stay (58% of patient stays > 6 hours in government EDs vs. 86% of patient stays 1–6 hours in private EDs, p = 0.009). Conclusions: EDs in Quito varied widely with respect to annual visit volume, ability to treat different pathologies 24/7, and resources. Most EDs are functioning at or over capacity, and a substantial number have long lengths of stay. Further research and investment in emergency care could help increase the capacity and efficiency of EDs in Ecuador.

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.

Introduction: Ninety percent of all injury-related deaths occur in low- and middle-income countries. The WHO recommends short, resource-specific trauma courses for healthcare providers. Studies show that teaching trauma courses to medical students in developed countries leads to significant increases in knowledge and skill. High costs hinder widespread and sustained teaching of these courses in low-income countries. Methods: A two-day trauma course was designed for students at Moi College of Health Sciences in Eldoret, Kenya. Participants underwent pre- and post-course written and simulation testing and rated their confidence in 21 clinical scenarios and 15 procedures pre- and post-course using a five point Likert scale. A subset of the students was re-evaluated nine months post-course. Using the paired t-test, mean written, simulation and confidence scores were compared pre-course, immediately post-course and nine months post-course. Results: Twenty-two students were enrolled. Written test score means were 61.5% pre-course and 76.9% post-course, mean difference 15.5% (p

Pediatric trauma is a significant public health problem in resource-constrained settings; however, the epidemiology of injuries is poorly defined in Rwanda. This study describes the characteristics of pediatric trauma patients transported to the emergency department (ED) of the Centre Hospitalier Universitaire de Kigali by emergency medical services in Kigali, Rwanda.This cohort study was conducted at the Centre Hospitalier Universitaire de Kigali from December 2012 to February 2015. Patients 15 years or younger brought by emergency medical services for injuries to the ED were included. Prehospital and hospital-based data on demographics, injury characteristics, treatments, and outcomes were gathered.Data from 119 prehospital patients were accrued, with corresponding hospital data for 64 cases. The median age was 9.5 years, with most patients being male (67.2%). Injured children were most frequently brought from a street setting (69.6%). Road traffic injuries accounted for 69.4% of all mechanisms, with more than two thirds due to pedestrians being struck. Extremity trauma was the most common region of injury (53.1%), followed by craniofacial (46.8%). The most frequent ED interventions were analgesia (66.1%) and intravenous fluids (43.6%). Half of the 16 obtained head computed tomography scans demonstrated acute pathology. Twenty-eight patients (51.9%) were admitted, with 57.1% requiring surgery and having a median in-hospital care duration of 9 days (range, 1-122 days).In this cohort of Rwandan pediatric trauma patients, injuries to the extremities and craniofacial regions were most common. Theses traumatic patterns were predominantly due to road traffic injury, suggesting that interventions addressing the prevention of this mechanism, and treatment of the associated injury patterns, may be beneficial in the Rwandan setting.

Injuries account for 10% of the global burden of disease, resulting in approximately 5.8 million deaths annually. Trauma registries are an important tool in the development of a trauma system; however, limited resources in low- and middle-income countries (LMIC) make the development of high-quality trauma registries challenging. We describe the development of a LMIC trauma registry based on a robust retrospective chart review, which included data derived from prehospital, emergency centre and inpatient records.This paper outlines our methods for identifying and locating patients and their medical records using pragmatic and locally appropriate record linkage techniques. A prehospital database was queried to identify patients transported to University Teaching Hospital - Kigali, Rwanda from December 2012 through February 2015. Demographic information was recorded and used to create a five-factor identification index, which was then used to search OpenClinic GA, an online open source hospital information system. The medical record number and archive number obtained from OpenClinic GA were then used to locate the physical medical record for data extraction.A total of 1668 trauma patients were transported during the study period. 66.7% were successfully linked to their medical record numbers and archive codes. 94% of these patients were successfully linked to their medical record numbers and archive codes were linked by four or five of the five pre-set identifiers. 945 charts were successfully located and extracted for inclusion in the trauma registry. Record linkage and chart extraction took approximately 1256 h.The process of record linkage and chart extraction was a resource-intensive process; however, our unique methodology resulted in a high linkage rate. This study suggests that it is feasible to create a retrospective trauma registry in LMICs using pragmatic and locally appropriate record linkage techniques.Les blessures sont responsables de 10% de la charge mondiale de morbidité, résultant sur environ 5,8 millions de décès par an. Les registres des traumatismes constituent un outil important pour le développement d’un système sur les traumatismes; cependant, les ressources limitées qui caractérisent les pays à revenu faible et intermédiaire font que le développement de registres des traumatismes de qualité est difficile. Nous décrivons le développement d’un registre des traumatismes dans les pays à revenu faible et intermédiaire à partir d’un examen rétrospectif approfondi des dossiers incluant des données tirées des registres pré-hospitaliers, des services d’urgence et des patients hospitalisés.Cet article décrit les méthodes dont nous disposons pour identifier et localiser les patients et leurs dossiers médicaux en utilisant des techniques de couplage de dossiers pragmatiques et localement appropriées. Une base de données pré-hospitalières a été interrogée afin d’identifier les patients transportés à l’Hôpital universitaire de Kigali, au Rwanda, de décembre 2012 à février 2015. Les informations démographiques ont été enregistrées et utilisées afin de créer un indice d’identification à cinq facteurs, utilisé ensuite pour mener une recherche dans OpenClinic GA, un système d’information hospitalière en open source accessible en ligne. Les numéros de dossiers médicaux et les codes d’archives obtenu par OpenClinic GA ont été ensuite utilisés pour localiser le dossier médical physique afin d’en extraire les données.Au total, 1668 patients ayant souffert de traumatisme ont été transportés au cours de la période à l’étude. 66,7% ont pu être couplés à leur numéro de dossier médical et code d’archive. 94% de ces patients ont pu être couplés à 4 ou 5 des cinq identifiants préétablis. 945 fichiers ont pu être localisés et extraits pour être intégrés au registre des traumatismes. Le couplage des dossiers et l’extraction des fiches ont nécessité environ 1 256 heures.Le processus de couplage de dossiers et d’extraction des fiches a nécessité des ressources considérables; cependant, notre méthodologie unique a résulté sur un taux de couplage élevé. Cette étude suggère qu’il est possible de créer un registre des traumatismes rétrospectif dans les pays à revenu faible et intermédiaire en utilisant des techniques de couplage de dossiers localement appropriées.

The incidence of poisonous snakebites has regional variance. Health care providers' knowledge and comfort in treating these envenomated patients depends on the density of poisonous snakes in their environment, with practitioners in the southern U.S. typically treating more exposed patients than those in colder regions in the North. We present a rare case of a confirmed copperhead snakebite that occurred in Rhode Island. We will review Copperhead bites, clinical management and treatment options.

A wide clinical spectrum of bacteremic disease caused by Fusobacterium has been presented in this journal. We wish to extend this spectrum by presenting a case of myopericarditis resulting from a liver abscess caused by F. nucleatum. While F. nucleatum plays an important role in periodontal disease, and has been isolated from skin ulcers, liver abscesses, urinary tract infections, and endocarditis, a single case of F. nucleatum-induced pericarditis is documented in the literature.