Developing and Testing a High-Fidelity Simulation Scenario for an Uncommon Life-Threatening Disease: Severe Malaria

Background. Severe malaria is prevalent globally, yet it is an uncommon disease posing a challenge to education in nonendemic countries. High-fidelity simulation (sim) may be well suited to teaching its management. Objective. To develop and evaluate a teaching tool for severe malaria, using sim. Methods. A severe malaria sim scenario was developed based on 5 learning objectives. Sim sessions, conducted at an academic center, utilized METI ECS mannequin. After sim, participants received standardized debriefing and completed a test assessing learning and a survey assessing views on sim efficacy. Results. 29 participants included 3rd year medical students (65%), 3rd year EM residents (28%), and EM nurses (7%). Participants scored average 85% on questions related to learning objectives. 93% felt that sim was effective or very effective in teaching severe malaria, and 83% rated it most effective. All respondents felt that sim increased their knowledge on malaria. Conclusion. Sim is an effective tool for teaching severe malaria in and may be superior to other modalities

Perceptions of short-term medical volunteer work: a qualitative study in Guatemala

BACKGROUND: Each year medical providers from wealthy countries participate in short-term medical volunteer work in resource-poor countries. Various authors have raised concern that such work has the potential to be harmful to recipient communities; however, the social science and medical literature contains little research into the perceptions of short-term medical volunteer work from the perspective of members of recipient communities. This exploratory study examines the perception of short-term medical volunteer work in Guatemala among groups of actors affected by or participating in these programs. METHODS: The researchers conducted in-depth, semi-structured interviews with 72 individuals, including Guatemalan healthcare providers and health authorities, foreign medical providers, non-medical personnel working on health projects, and Guatemalan parents of children treated by a short-term volunteer group. Detailed notes and summaries of these interviews were uploaded, coded and annotated using Atlas.ti (Scientific Software Development GmbH, Berlin) to identify recurrent themes from the interviews. RESULTS: Informants commonly identified a need for increased access to medical services in Guatemala, and many believed that short-term medical volunteers are in a position to offer improved access to medical care in the communities where they serve. Informants most frequently cited appropriate patient selection and attention to payment systems as the best means to avoid creating dependence on foreign aid. The most frequent suggestion to improve short-term medical volunteer work was coordination with and respect for local Guatemalan healthcare providers and their communities, as insufficient understanding of the country's existing healthcare resources and needs may result in perceived harm to the recipient community. CONCLUSION: The perceived impact of short-term medical volunteer projects in Guatemala is highly variable and dependent upon the individual project. In this exploratory study, project characteristics were identified that are consistently perceived to be either positive or negative. These findings have direct implications for anyone involved in the planning and execution of short-term medical volunteer projects, including local and foreign medical team members, project planners and coordinators, and health authorities. Most importantly, this preliminary study suggests avenues for future study and evaluation of the impact of short-term medical volunteer programs on local health care services

Toward a theory of local legitimacy by MNEs in developing nations: Newmont mining and health sustainable development in Peru

This paper describes a current initiative by Newmont Mining Corporation (Newmont) to develop sustainable community benefit in communities around its mining operations in Peru in response to heightened criticism of Newmont by non-government organizations and the media. Using anthropologically oriented methods, a community health assessment project in an area of projected mining is described in detail in this paper. This case adds to London and Hart's social embeddedness strategy for multi-national enterprises (MNEs) working in developing nations by introducing a locally-based community interaction model, which we describe as a local legitimacy strategy, in an effort to bring about sustainable development in the communities that surround a MNE's production activities. The components of our local legitimacy strategy include co-analysis of community needs by MNEs and community partners, and planning and investment in developments to enhance the social fabric and the physical infrastructure needs of communities. The developing world is getting better at publicizing and monitoring the work of MNEs. We argue that it will be increasingly necessary for MNEs, like Newmont, to add local sustainable benefit into their strategic mix to gain the social license and legitimacy that is needed to operate in poorer communities

CT Before Lumbar Puncture in Suspected Meningitis in Botswana: How Established Guidelines May Not Apply / Tomodensitométrie Avant Ponction Lombaire en Cas de Suspicion de Méningite au Botswana: Comment les Directives Classiques Peuvent ne Pas s’Appliquer

English Introduction According to established guidelines from high-income countries, computed tomography of the head (CT) is indicated before lumbar puncture (LP) in the evaluation of suspected meningitis in HIV patients. In Botswana, meningitis in HIV-infected patients is common but CT is not widely available. Objective Develop a rational, evidence-based approach to CT use in the emergency evaluation of suspected meningitis in a population with high HIV prevalence. Methods Emergency center (EC) staff at Princess Marina Hospital in Gaborone, Botswana, reviewed indications for CT and LP in suspected meningitis. The authors considered existing evidence for CT before LP (mostly from high-income countries) and considered the epidemiology of central nervous system infections in Southern Africa. Draft guidelines were circulated to emergency center doctors and nurses, and to specialists in other hospital departments for review and comment before finalization. Result Available literature seems to indicate that in Botswana it would be possible to significantly limit the use of head CT before LP in HIV positive patients without increasing the incidence or risk of herniation. The guideline includes scenarios where an LP might be indicated in the presence of focal neurological findings and in the absence of a CT, in contradiction to established guidelines. Discussion The applicability of established guidelines for CT use in suspected meningitis is dependent on local epidemiology and resources. French Introduction Selon les directives classiques provenant des pays à revenu élevé, la tomodensitométrie (TDM) de la tête est indiquée avant une ponction lombaire (PL) pour l’évaluation d’une possible méningite chez les patients infectés par le VIH. Au Botswana, la méningite chez les patients infectés par le VIH est courante mais la TDM n’est pas souvent disponible. Objectif Développer une approche rationnelle fondée sur des preuves relative à l’utilisation de la TDM en cas d’évaluation d’urgence d’une possible méningite au sein d’une population à forte prévalence du VIH. Méthodes Le personnel du Centre d’Urgences (CU) de l’hôpital Princess Marina à Gaborone, Botswana, a examiné des prescriptions de TDM et de PL en cas de suspicion de méningite. Les auteurs se sont penchés sur les cas existants de TDM avant PL (la plupart provenant de pays à revenus élevés) et ont examiné l’épidémiologie des infections du système nerveux central en Afrique australe. Des directives provisoires ont été distribuées à des médecins et des infirmières de centres d’urgences et à des spécialistes dans d’autres services hospitaliers pour examen et commentaires avant finalisation. Résultat Les publications disponibles semblent indiquer qu’au Botswana, il serait possible de limiter fortement l’utilisation de la TDM de la tête avant une PL chez les patients séropositifs sans augmenter l’incidence ou le risque d’engagement cérébral. La directive comprend des scénarios dans lesquels une PL pourrait être indiquée en présence de signes neurologiques focaux et en l’absence d’une TDM, contrairement à ce que préconisent les directives classiques. Discussion L’applicabilité des directives classiques relatives à l’utilisation de la TDM dans des cas de suspicion de méningite dépend de l’épidémiologie et des ressources locales

Blunt Abdominal Trauma Patients Are at Very Low Risk for Intra-Abdominal Injury after Emergency Department Observation

<p>Introduction: Patients are commonly admitted to the hospital for observation following blunt abdominal trauma (BAT), despite initially negative emergency department (ED) evaluations. With the current use of screening technology, such as computed tomography (CT) of the abdomen and pelvis, ultrasound, and laboratory evaluations, it is unclear which patients require observation. The objective of this study was to determine the prevalence of intra-abdominal injury (IAI) and death in hemodynamically normal and stable BAT patients with initially negative ED evaluations admitted to an ED observation unit and to define a low-risk subgroup of patients and assess whether they may be discharged without abdominal/pelvic CT or observation. Methods: This was a retrospective cohort study performed at an urban level 1 trauma center and included all BAT patients admitted to an ED observation unit as part of a BAT key clinical pathway. All were observed for at least 8 hours as part of the key clinical pathway, and only minors and pregnant women were excluded. Outcomes included the presence of IAI or death during a 40-month follow-up period. Prior to data collection, low-risk criteria were defined as no intoxication, no hypotension or tachycardia, no abdominal pain or tenderness, no hematuria, and no distracting injury. To be considered low risk, patients needed to meet all low-risk criteria. Results: Of the 1,169 patients included over the 2-year study period, 29% received a CT of the abdomen and pelvis, 6% were admitted to the hospital from the observation unit for further management, 0.4% (95% confidence interval [CI], 0.1%–1%) were diagnosed with IAI, and 0% (95% CI, 0%–0.3%) died. Patients had a median combined ED and observation length of stay of 9.5 hours. Of the 237 (20%) patients who met low-risk criteria, 7% had a CT of the abdomen and pelvis and 0% (95% CI, 0%–1.5%) were diagnosed with IAI or died. Conclusion: Most BAT patients who have initially negative ED evaluations are at low risk for IAI but still require some combination of observation and CT. A subgroup of BAT patients may be safely discharged without CT or observation after the initial evaluation. [West J Emerg Med. 2011;12(4):496–504.]</p

Epidemiology of patients presenting to the emergency centre of Princess Marina Hospital in Gaborone, Botswana

Emergency medicine is a newly recognized specialty in Botswana and the country launched an emergency medicine residency in January 2011. Data regarding the practice of emergency medicine in Botswana are limited. This study reviewed 1 year of patient presentations to the emergency centre of Princess Marina Hospital, the country’s main referral hospital located in the capital city, Gaborone. Methods: Epidemiologic data of all patients presenting to the emergency centre between May 2010 and April 2011 were extracted into a database. The diagnoses of a random sample of patient presentations were coded using the categories outlined by the Clinical Classifications Software (CCS) for ICD-10. For ease of analysis, several CCS categories were grouped together for subsequent analysis. Results: 24,905 patient encounters were recorded during the study period. A large proportion of patients were aged between 25 and 50 years old. 20% of patients presented with a traumatic injury. The most common diagnoses across all ages included trauma, pregnancy complications, gastrointestinal disorders, and pneumonia. Conclusion: These results can inform the development of emergency medicine education and acute care systems in Botswana

Training Hospital Providers in Basic CPR Skills in Botswana: Acquisition, Retention and Impact of Novel Training Techniques

Objective Globally, one third of deaths each year are from cardiovascular diseases, yet no strong evidence supports any specific method of CPR instruction in a resource-limited setting. We hypothesized that both existing and novel CPR training programs significantly impact skills of hospital-based healthcare providers (HCP) in Botswana. Methods HCP were prospectively randomized to 3 training groups: instructor led, limited instructor with manikin feedback, or self-directed learning. Data was collected prior to training, immediately after and at 3 and 6 months. Excellent CPR was prospectively defined as having at least 4 of 5 characteristics: depth, rate, release, no flow fraction, and no excessive ventilation. GEE was performed to account for within subject correlation. Results Of 214 HCP trained, 40% resuscitate ≥1/month, 28% had previous formal CPR training, and 65% required additional skills remediation to pass using AHA criteria. Excellent CPR skill acquisition was significant (infant: 32% vs. 71%, p \u3c 0.01; adult 28% vs. 48%, p \u3c 0.01). Infant CPR skill retention was significant at 3 (39% vs. 70%, p \u3c 0.01) and 6 months (38% vs. 67%, p \u3c 0.01), and adult CPR skills were retained to 3 months (34% vs. 51%, p = 0.02). On multivariable analysis, low cognitive score and need for skill remediation, but not instruction method, impacted CPR skill performance. Conclusions HCP in resource-limited settings resuscitate frequently, with little CPR training. Using existing training, HCP acquire and retain skills, yet often require remediation. Novel techniques with increased student: instructor ratio and feedback manikins were not different compared to traditional instruction

Yes, not now, or never: an analysis of reasons for refusing or accepting emergency department-based take-home naloxone.

OBJECTIVE: Take-home naloxone (THN) reduces deaths from opioid overdose. To increase THN distribution to at-risk emergency department (ED) patients, we explored reasons for patients' refusing or accepting THN. METHODS: In an urban teaching hospital ED, we identified high opioid overdose risk patients according to pre-specified criteria. We offered eligible patients THN and participation in researcher-administered surveys, which inquired about reasons to refuse or accept THN and about THN dispensing location preferences. We analyzed refusal and acceptance reasons in open-ended responses, grouped reasons into categories (absolute versus conditional refusals,) then searched for associations between patient characteristics and reasons. RESULTS: Of 247 patients offered THN, 193 (78.1%) provided reasons for their decision. Of those included, 69 (35.2%) were female, 91 (47.2%) were under age 40, 61 (31.6%) were homeless, 144 (74.6%) reported injection drug use (IDU), and 131 (67.9%) accepted THN. Of 62 patients refusing THN, 19 (30.7%) felt "not at risk" for overdose, while 28 (45.2%) gave conditional refusal reasons: "too sick," "in a rush," or preference to get THN elsewhere. Non-IDU was associated with stating "not at risk," while IDU, homelessness, and age under 40 were associated with conditional refusals. Among acceptances, 86 (65.7%) mentioned saving others as a reason. Most respondents preferred other dispensing locations beside the ED, whether or not they accepted ED THN. CONCLUSION: ED patients refusing THN felt "not at risk" for overdose or felt their ED visit was not the right time or place for THN. Most accepting THN wanted to save others