Journal of Emergency Medicine, Trauma and Acute Care: Most Cited Articles http://www.qscience.com/content/journals/jemtac?TRACK=RSS Please follow the links to view the content. Evolution of emergency medical services in Saudi Arabia http://www.qscience.com/content/journals/10.5339/jemtac.2017.4?TRACK=RSS Aim: The purpose of this study was to provide an overview of the evolution of emergency medical services (EMS) in Saudi Arabia to describe its history, organisational service providers, governance, EMS statistics and the educational development of the field with the disparity of educational approaches. Background: The EMS is an important part of the healthcare system as it is often the first point of contact for medical emergencies. The EMS in Saudi Arabia has seen a number of positive changes over the past decade, some of which include the development of several university and college programs dedicated to teaching EMS, the evaluation of the profession from a post-employment first aid model into a pre-employment bachelor's degree model, the generous governmental scholarship grants overseas and the official accreditation of EMS as a profession. It has been approximately nine years since the first EMS bachelor's degree programs were developed in Saudi Arabia, some of which were directly adopted from universities in developed countries such as Australia. Despite these positive changes, the current EMS system in Saudi is faced with many challenges, both organisational and educational, including the lack of research, community involvement, the educational status of practitioners and the inconsistencies of statistics relating to response time and rate of transfer. This paper describes the history of EMS in Saudi Arabia with a specific focus on identifying the disparity in the educational outcomes and approaches adopted by colleges and universities in the Kingdom. Methods: The data utilised for the research of the EMS profession in Saudi Arabia were obtained from the literature using search tools such as MEDLINE, Google Scholar, Saudi health journals, Saudi university websites, government reports and statistics. Conclusion: The EMS profession in Saudi Arabia has advanced greatly in the past 12 years. Yet there is still scope for considerable improvement, especially with regards to developing empirically identified core competencies for EMS bachelor's degree graduates. There is also the need for providing more outreach to the public to improve awareness of current services and available training, building more collaboration between the industry employers and academic institutions and investing further in EMS research through the development of Saudi-based postgraduate master's and PhD EMS degrees. This paper is the first to provide an overview of the EMS service in Saudi Arabia, for institutions and researchers to gain a better understanding of the history and current standing of the service from an educational and operational perspective. Talal AlShammari, Paul Jennings and Brett Williams Mon Jan 28 15:14:38 UTC 2019Z Disaster medicine curricula in Saudi Arabian medical schools http://www.qscience.com/content/journals/10.5339/jemtac.2015.8?TRACK=RSS Background: Disaster medicine training in medical school is a key element of disaster preparedness, and several international educational authorities have called for an increase in this specific type of training. The objective of this study was to assess the current state of disaster medicine education in the Kingdom of Saudi Arabia. Methods: All 30 medical schools in Saudi Arabia were invited to participate in the study, and a 25-item online survey was sent to those that consented. Results: The response rate was 67%. Only three of the responding 20 universities currently have disaster medicine programs, and they spend an average of three hours per year on the subject. Respondents without disaster medicine curricula indicated that a mandatory, accredited course in the final three years of the six-year program was their preferred method for implementation, and most favored a blended approach. Conclusions: The study found that there is a paucity of disaster medicine programs in Saudi Arabia. Most schools indicated a willingness to implement such training in their undergraduate programs but cited lack of an adequate number of relevant professionals as a major impediment. Nidaa Bajow, Ahmadreza Djalali, Pier Luigi Ingrassia, Hussein Ageely, Ibrahim Bani and Francesco Della Corte Sat Apr 13 19:09:32 UTC 2019Z Bilateral intratonsillar abscesses: A first case report in an adult patient http://www.qscience.com/content/journals/10.5339/jemtac.2015.7?TRACK=RSS Intratonsillar abscesses are not uncommon. The reported incidence of unilateral tonsillar abscess is 5 percent. There have not been any cases of bilateral tonsillar involvement previously reported. The clinical presentation of intratonsillar abscess are similar to peritonsillar abscess. Negative aspiration of pus from a case of intratonsillar abscess presumed to be peritonsillar abscess can lead to misdiagnosis and subsequent delay in treatment. We report a case of a 42-year-old diabetic patient with odynophagia, dysphagia, voice change, stridor and fever for a duration of four days. CT scan was performed in view of trismus and neck swelling as the initial provisional diagnosis of deep neck abscesses was made. The CT scan showed bilateral intratonsillar abscesses without involvement of other neck spaces. ‘Hot’ tonsillectomy was immediately performed after which the patient recovered well. Although uncommon, a high index of suspicion is required to diagnose intratonsillar abscess, especially in patient groups with high-risk factor e.g., diabetes mellitus with severe clinical complications. Jack Pein Cheong, Aun Wee Chong and Kein Seong Mun Tue Mar 12 09:45:06 UTC 2019Z Prediction of critical haemorrhage following trauma: A narrative review http://www.qscience.com/content/journals/10.5339/jemtac.2016.3?TRACK=RSS Introduction: Traumatic haemorrhagic shock can be difficult to diagnose. Models for predicting critical bleeding and massive transfusion have been developed to aid clinicians. The aim of this review is to outline the various available models and report on their performance and validation. Methods: A review of the English and non-English literature in Medline, PubMed and Google Scholar was conducted from 1990 to September 2015. We combined several terms for i) haemorrhage AND ii) prediction, in the setting of iii) trauma. We included models that had at least two data points. We extracted information about the models, their developments, performance and validation. Results: There were 36 different models identified that diagnose critical bleeding, which included a total of 36 unique variables. All models were developed retrospectively. The models performed with variable predictive abilities–the most superior with an area under the receiver operating characteristics curve of 0.985, but included detailed findings on imaging and was based on a small cohort. The most commonly included variable was systolic blood pressure, featuring in all but five models. Pattern or mechanism of injury were used by 16 models. Pathology results were used by 15 models, of which nine included base deficit and eight models included haemoglobin. Imaging was utilised in eight models. Thirteen models were known to be validated, with only one being prospectively validated. Conclusions: Several models for predicting critical bleeding exist, however none were deemed accurate enough to dictate treatment. Potential areas of improvement identified include measures of variability in vital signs and point of care imaging and pathology testing. Alexander Olaussen, Prasanthan Thaveenthiran, Mark C. Fitzgerald, Paul A. Jennings, Jessica Hocking and Biswadev Mitra Mon Jan 28 15:14:25 UTC 2019Z Identifying a safe site for intercostal catheter insertion using the mid-arm point (MAP) http://www.qscience.com/content/journals/10.5339/jemtac.2017.3?TRACK=RSS Background: Over 85% of chest injuries requiring surgical intervention can be managed with tube thoracostomy/intercostal catheter (ICC) insertion alone. However, complication rates of ICC insertion have been reported in the literature to be as high as 37%. Insertional complications, including the incorrect identification of the safe zone chest wall location for ICC placement, are common issues, with up to 41% of insertions occurring outside of this safe area. A new biometric approach using the patient's proportional skeletal upper limb anatomy to allow correct identification of the chest wall skin site for ICC insertion may reduce complications. Aim: The aim of this study was to examine the performance of the mid-arm point (MAP) method in identifying the safe zone for ICC insertion. Methods: Thirty healthy volunteers were recruited from The Alfred Hospital, a Level I Adult Trauma Centre in Melbourne, Australia. Blinded investigators used the MAP to measure the mid-point of the adducted arm of each volunteer bilaterally. A skin marking was placed on the anterior axillary line of the adjacent chest wall, and with the arm then abducted to 90 degrees, the underlying intercostal space was identified. Results: Using the MAP method, all of the 120 measurements fell within the ‘safe zone’ of the fourth to sixth intercostal spaces bilaterally. The median intercostal space identified was the fifth space, with investigators finding this in 86% of measurements independent of age, sex, height, weight or side. Conclusion: A simple technique using the MAP is a reliable marker for the identification of the safe zone for ICC insertion in healthy volunteers. The clinical utility for patients undergoing pleural decompression and drainage needs prospective evaluation. Fei Bing, Mark Fitzgerald, Alexander Olaussen, Pete Finnegan, Gerard O'Reilly, Rob Gocentas, Helen Stergiou, Anna Korin, Silvana Marasco and David McGiffin Mon Jan 28 15:14:49 UTC 2019Z Children receive less analgesia in general ERs than adults: A retrospective study http://www.qscience.com/content/journals/10.5339/jemtac.2016.1?TRACK=RSS Background/Introduction: Oligoanalgesia is a common phenomenon in the Emergency Department (ED) with children being especially at risk. However, the extent to which pediatric patients are being undertreated for acute pain in relation to their adult counterparts is not well understood, especially in general (i.e., mixed adult and pediatric) EDs. This study was designed to compare the pain medication received by adult and pediatric patients with appendicitis presenting to a general ED. Methods: A retrospective chart review of 165 patients, 92 adult (mean age: 35.7 ± 15.7 years) and 73 pediatric (mean age: 11.0 ± 3.0 years) with a discharge diagnosis of “appendicitis” were included in this study. Demographic information as well as data regarding type, timing, and received amount of pain medication were collected. Adult and pediatric data were then compared using independent t-test or chi-square analysis. Effect sizes were also calculated. Results: Pediatric patients were significantly more likely than adult patients to not receive any analgesia during their ED stay (58.9% vs 20.7%, p>0.001, Cramer's V = 0.39). They were also significantly less likely to receive opioid analgesics, compared to adults (27.4% vs. 71.7%, p>0.001, Cramer's V = 0.44). Finally, mean pain scores recorded at presentation were significantly lower for children vs. adults (6.5 vs 7.2 out of 10, p = 0.015, r = 0.20). Conclusion: In this sample, pediatric patients with appendicitis presenting to a general emergency department received less opioid pain medication, and less pain medication in general, than their adult counterparts. Erwin Karreman, Christopher S. Krause and Sheila Smith Mon Jan 28 15:14:29 UTC 2019Z Disconnect between available literature and clinical practice: Exploring gaps in the management of t-BPPV in the emergency department http://www.qscience.com/content/journals/10.5339/jemtac.2017.6?TRACK=RSS Background: Healthcare costs associated with the diagnosis of benign paroxysmal positional vertigo (BPPV) alone approach $2 billion per year in the United States. Post-traumatic BPPV (t-BPPV) is well recognized, and can be managed with simple bedside physical maneuvers. Despite the availability of literature and clear guidelines supporting this approach, physical maneuvers are underutilized. The aim of this study was to explore the reasons for this practice disagreement. Methods: A cross-sectional survey of emergency physicians (EP) and non-emergency physicians (Non-EPs) managing head injury patients was conducted. The survey questions were aimed to explore the attitude of these frontline healthcare providers towards the diagnosis and management of t-BPPV in head injury patients. Results: A total of 102 physicians completed the survey. Of them, male physicians constituted 87.2%, and the majority were working as emergency physicians (80.4%). Although nearly three-fourths (72.5%; n = 74) of the participants admitted that it is important to explore the possibility of t-BPPV in patients with head injury, only one-fifth of the participating physicians (20.6%; 21 of 102) confirmed that they would investigate for t-BPPV. A lack of knowledge about t-BPPV in more than half of the study participants (55.9%; n = 57) was the main reason for them not probing the possibility of t-BPPV. Conclusion: To close the gap between available evidence-based guidelines and actual clinical practice, there is a need for raising awareness about this condition. Addressing the training needs of frontline healthcare providers to use physical maneuvers such as Dix–Hallpike (DHM) and canalith repositioning (CRP) maneuvers in the management of t-BPPV is an important step that needs to be taken. Khalid Bashir, Sameer Pathan, Saleem Farook, Muhammad Masood Khalid and Sameh Zayed Mon Jan 28 15:14:22 UTC 2019Z Simplifying simulated practice for healthcare professionals and educators http://www.qscience.com/content/journals/10.5339/jemtac.2016.icepq.79?TRACK=RSS Introduction: Simulation is almost synonymous with computerised mannequins although they are not always essential components of the learning experience as what often matters most is the facilitation process of the learning experience rather than the technology. Methods: We developed Visually Enhanced Mental Simulation (VEMS) for staff to demonstrate cognitive and decision making skills away from the practical context. Scenario participants are oriented by facilitators to the VEMS process which is a simulation approach that involves a whiteboard, laminated cards, and a poster to represent equipment and the patient. It requires participants to verbalise thoughts and actions including equipment settings, and actual communication with the patient and bystanders represented by the facilitators. Information like physiological parameters and interventions made by the participating crew are written on the whiteboard. Scenarios use the same scripts as what is prepared for full-scale simulation and are followed by a debriefing. It is complemented by parallel skills sessions, and ultimately both aspects are combined into full-scale scenario-based simulation. Results: VEMS has been facilitated with uni/multi-professional teams of healthcare professionals for pre-hospital, interfacility, and handover scenarios. Comparison between VEMS and mannequin-based scenarios is ongoing and currently shows just a slightly less positive rating for VEMS although they advocate for this modality prior to full-scale simulation. VEMS reduces pressure on equipment demand and the staff engagement is such that similar clinical practitioner's mistakes are “observed” in both types of simulation approaches. Conclusion: VEMS can be run almost anywhere as it requires a minimum of equipment but still requires time and experienced facilitators. Briefing about the process and expectations are as important as the preparation of the scenario script and clinical knowledge and facilitation style of the facilitators. VEMS can be very engaging for multiprofessional teams and address learning outcomes similar to what would be achieved in full-scale simulation. Guillaume Alinier, John Meyer, Vernon Naidoo and Craig Campbell Sat Apr 13 19:09:26 UTC 2019Z Indications for blood transfusion following trauma - a pilot study http://www.qscience.com/content/journals/10.5339/jemtac.2015.4?TRACK=RSS Background: Indications for blood transfusion during trauma resuscitation remain poorly understood. This study aimed to objectively determine the range of factors that lead to initiation of blood transfusion during trauma resuscitation. Design and method: This was a prospective, observational pilot study. A questionnaire was distributed to all clinicians following any transfusion of packed red blood cells during trauma resuscitation. The questionnaire focused on the clinicians’ opinion regarding the indication for red cell transfusion. Results: Complete data on 37 individual episodes of transfusion initiation in the Emergency Department were collected. The most commonly used pre-hospital factors that influenced initiation of transfusion was a pre-hospital systolic blood pressure (SBP) of < 100 mm Hg (65%), pre-hospital tachycardia (38%) or estimated blood loss of >1 L (30%) by paramedics. On arrival to hospital, the activation of a massive transfusion protocol was the commonest indication for transfusion, followed by a positive FAST examination (43%), low systolic blood pressure (35%), tachycardia (32%) or pallor (35%). Blood tests to guide initiation of transfusion were less commonly used with 9 (24%) patients transfused for a low haemoglobin level and 6 (16%) patients transfused for coagulopathy. Conclusions: A combination of objective pre- and in-hospital vital signs, together with subjective indicators such as pallor and estimation of blood loss guided initiation of transfusion following injury. Arun Ilancheran, Fatima Rahman and Biswadev Mitra Sat Apr 13 19:09:54 UTC 2019Z An overwhelming post-splenectomy infection (OPSI) http://www.qscience.com/content/journals/10.5339/jemtac.2012.13?TRACK=RSS We present the case of a 25 year-old man who had a splenectomy five years previously following a road traffic accident (RTA). He presented to our A&E department one evening with fever and upper abdominal pain associated with nausea & vomiting. Clinical examination was unremarkable. Initial investigations revealed only pyuria. He was treated symptomatically along with parenteral antibiotic and admitted to the general medical ward. Within few hours he deteriorated rapidly with septic shock, multi-organ failure, disseminated intravascular coagulation (DIC) and eventually cardio-respiratory arrest. Despite all resuscitative measures he died within few hours of admission. Splenectomized patients are prone to develop severe infection, including sepsis and meningitis, due to OPSI, or overwhelming post-splenectomy infection. Presentation may be mild, but the course is rapid and the prognosis is very poor, even in young people. It is important that splenectomized patients receive vaccines according to guidelines, take antibiotic prophylaxis and are educated to seek medical attention at the earliest sign of even minor infections. O Elbadawi, SR Ali, A Waheed and S Khan Mon Jan 28 15:14:47 UTC 2019Z