“Resuscitate and Push”:End-of-Life Care Experiences of Healthcare Staff in the Emergency Department – A Hermeneutic Phenomenological Study

Objective: Care in the emergency department focuses significantly on delivering lifesaving/ life-sustaining clinical actions, often with limited attention to health-related suffering even at the end-of-life. How healthcare staff experience and navigate through the end-of-life phase remains minimally explored. Thus, this study aimed to uncover the lived experiences of emergency department staff at the end-of-life. Methods: van Manen’s hermeneutic phenomenological approach was used. Nineteen healthcare staff were purposively recruited and interviewed. Interviews were audio-taped, transcribed verbatim, and thematic categories formulated. The existential lifeworld themes (corporeality, relationality, spatiality, and temporality) were used as heuristic guides for reflecting and organizing the lived experiences of participants. Results: The overarching category, ‘resuscitate and push’, was captured as corporeality (resisting death and dying); relationality (connectedness to the body of the patient; and lacking support for family and self); spatiality (navigating through a liminal space and lack of privacy for patients); and temporality (having limited to no time for end-of-life care and grieving). The end-of-life space was unpleasant. Although participants experienced helplessness and feelings of failure, support systems to help them to navigate through these emotions were lacking. Grief was experienced covertly and concealed by the entry of a new patient. Conclusion: End-of-life in the emergency department is poorly defined. In addition to shifting from the traditional emergency care model to support the streamlining of palliative care in the department, staff will require support with navigating through the liminal space, managing their grief, and developing a better working relationship with patients/ families

Burns in the middle belt of Ghana: A systematic review

Background: Burns are a major global public health issue affecting persons of all ages. Various studies have indicated that developing countries share a greater burden of the injury. Despite this fact, Ghana as a developing country lacks a burn repository and that makes it difficult to clearly understand the bigger picture of the injury. To this end, this study aimed to systematically review primary studies of burn occurrence in the country. Methodology: A comprehensive literature search was undertaken using PubMed, ScienceDirect, Google Scholar, MEDLINE and EMBASE. The keywords used were “burns, epidemiology, Ghana, injury, flame burn, scald burn, electric burn, chemical burn, contact burn and explosion”. Additional articles were identified by reviewing reference lists. The local journals such as the Postgraduate Medical Journal of Ghana were searched for the articles not indexed in PubMed or EMBASE. MOOSE guidelines were followed in executing this review. At the end of the selection process, seven papers remained and included in the study. Findings: Findings from this review identified that more males than females were involved in burn injuries. Persons within the paediatric age group (particularly those under 10 years of age) were particularly susceptible to burns. This notwithstanding it was noted that there is an increasing occurrence of burns among persons in the working class group (15 years–59 years). Scald was the most common injury among the paediatric age group whilst flame burn was most common among the adult population. The home was noted to be the commonest place for burn occurrence though some disasters at fuel filling stations were recorded. The occurrence of burn was associated with various burned surface area and from the studies reviewed it was noted that higher total burned surface area (TBSA) may be linked to increasing mortality rates. Length of hospitalisation ranged from less than 10 days to 760 days. Epilepsy was reported by one study as a pre-morbid condition. Conclusion: Burns represent a significant public health problem in Ghana and there is a need for the design of more effective intervention to reduce the occurrence of the injury. A larger scale research is imperative to investigate burns epidemiology from a national perspective. Keywords: Burns, Middle belt of Ghana, Epidemiology, Systematic revie

Comparative efficacy of low-dose versus standard-dose azithromycin for patients with yaws: a randomised non-inferiority trial in Ghana and Papua New Guinea

Summary: Background: A dose of 30 mg/kg of azithromycin is recommended for treatment of yaws, a disease targeted for global eradication. Treatment with 20 mg/kg of azithromycin is recommended for the elimination of trachoma as a public health problem. In some settings, these diseases are co-endemic. We aimed to determine the efficacy of 20 mg/kg of azithromycin compared with 30 mg/kg azithromycin for the treatment of active and latent yaws. Methods: We did a non-inferiority, open-label, randomised controlled trial in children aged 6–15 years who were recruited from schools in Ghana and schools and the community in Papua New Guinea. Participants were enrolled based on the presence of a clinical lesion that was consistent with infectious primary or secondary yaws and a positive rapid diagnostic test for treponemal and non-treponemal antibodies. Participants were randomly assigned (1:1) to receive either standard-dose (30 mg/kg) or low-dose (20 mg/kg) azithromycin by a computer-generated random number sequence. Health-care workers assessing clinical outcomes in the field were not blinded to the patient's treatment, but investigators involved in statistical or laboratory analyses and the participants were blinded to treatment group. We followed up participants at 4 weeks and 6 months. The primary outcome was cure at 6 months, defined as lesion healing at 4 weeks in patients with active yaws and at least a four-fold decrease in rapid plasma reagin titre from baseline to 6 months in patients with active and latent yaws. Active yaws was defined as a skin lesion that was positive for Treponema pallidum ssp pertenue in PCR testing. We used a non-inferiority margin of 10%. This trial was registered with ClinicalTrials.gov, number NCT02344628. Findings: Between June 12, 2015, and July 2, 2016, 583 (65·1%) of 895 children screened were enrolled; 292 patients were assigned a low dose of azithromycin and 291 patients were assigned a standard dose of azithromycin. 191 participants had active yaws and 392 had presumed latent yaws. Complete follow-up to 6 months was available for 157 (82·2%) of 191 patients with active yaws. In cases of active yaws, cure was achieved in 61 (80·3%) of 76 patients in the low-dose group and in 68 (84·0%) of 81 patients in the standard-dose group (difference 3·7%; 95% CI −8·4 to 15·7%; this result did not meet the non-inferiority criterion). There were no serious adverse events reported in response to treatment in either group. The most commonly reported adverse event at 4 weeks was gastrointestinal upset, with eight (2·7%) participants in each group reporting this symptom. Interpretation: In this study, low-dose azithromycin did not meet the prespecified non-inferiority margin compared with standard-dose azithromycin in achieving clinical and serological cure in PCR-confirmed active yaws. Only a single participant (with presumed latent yaws) had definitive serological failure. This work suggests that 20 mg/kg of azithromycin is probably effective against yaws, but further data are needed. Funding: Coalition for Operational Research on Neglected Tropical Diseases