Ups and down of emergency medicine in Iran: an urgent agenda

A startling high number emergency medicine (EM) residency positions in Iran remained unfilled in this year’s National Residency Examination. In fact, the unprecedented numbers of unoccupied EM residency training positions over the past few years had already shocked the specialty, but this year’s statistics are alarming. Working as an emergency physician has never been an easy task, yet, since its establishment as a specialty in Iran in the year 2000 (1,2), EM continued to attract applicants over years. The trend of disfavoring EM, which started a few years ago, has important implications for nationwide residency programs, applicants, and most importantly our patients. It has also contributed to a state of general anxiety within the EM community, who feel that EM is a “profession in peril”, perpetuating the situation and starting a vicious cycle. EM departments are struggling to find a solution to ensure that delivery of quality care amid staffing shortages, and the authorities in the Ministry of Health and Medical Education (MOHME) are trying to solve the problem by “supplemental offer”, in the hope of recruiting applicants for unclaimed spots. However, besides these temporizing measures, it is imperative to deep dive into the factors contributing to this unprecedented national trend in order to shed light on the factors behind it and the solutions ahead of us. The problem is multifaceted and influenced by a myriad of interconnected factors. It is partly driven by the current landscape of the healthcare system and the changes to specialty preferences by students (3) in general. Moreover, the trend seems to be present in other parts of the world as well (3). Yet, there are aspects that are unique or more significant for EM in Iran: As a specialty driven by the needs of the society, its existence requires constant support and recognition by the society (mainly represented in the health sector by MOHME). It seems that the current authorities have forgotten what the emergency rooms were like in the era before EM, and have taken the current situation of emergency healthcare for granted. This is represented not only in their speeches and statements, but also in their decisions regarding regulations for compensation. Establishment of EM as a specialty was a fundamental action toward improving emergency care (4,5), but it was too optimistic to think that it can solve the entire problem. More actions were needed including training other related providers and ancillary staff, restructuring the design of the departments, and changing the employment structure of ED healthcare providers. Eluded by the drastic changes created just by the introduction of competent and energetic EM physicians, the authorities neglected many of these crucial actions. In an effort to solve quickly a problem that existed for a long time, MOHME created a surge in EM positions, jeopardizing the quality of EM training programs and ignoring the supply-demand dynamics of the discipline. They even failed to consider the advice of the National Board of Emergency Medicine, who repeatedly warned them against the dangers of expanding the number of residency programs and training sites without enough quality assurance system in place. This mass production of emergency physicians with inconsistent qualities, considered by many as the main trigger of the shift in the situation of EM, require a detailed exploration in its own right. Surprisingly, the number of EM residency positions has increased in recent years, while the number of applicants continued to decline. High levels of burnout (resulting from poor compensation and financial reward mechanisms, high prevalence of violence (6,7), overcrowding of the EDs with extended boarding of the patients, and exacerbated by the COVID pandemic) has disappointed many EM practitioners who selected this specialty with great enthusiasm. Some of these people role model burnout explicitly during their shifts and fail to interact positively with medical students, who are potential applicants of EM residency. This atmosphere of despair reassure the hesitant applicants not to opt this field as the future of their carriers. As emergency physicians, we are accustomed to dealing with unanticipated, unfavorable events and we have been trained to handle these conditions calmly and efficiently. In this case, too, we must take this situation as an opportunity to shape the future of our specialty. Convincing those who are responsible for healthcare workforce planning to work in tandem with the authorities in charge of graduate medical training in order to find logical and feasible solutions including an organized approach to a balanced workforce is a first step. This requires diplomacy and tactfulness of the EM community, and perhaps more importantly, an open mind and a listening ear on the administration side.&nbsp

Emergency Medicine as an Academic Discipline: Giants strides along an Endless Path

For many years, emergency care had been abandoned and left in the hands of practitioners whose main interest was not working in the not-so-much respected “emergency room (ER)”. They were usually obliged to serve the first years of their career in the ER, where senior colleagues did not want to be bothered with, before they were allowed to focus on their ultimate goals. This fact had led to delivery of a fragmented, suboptimal care to the patients who were seeking care for the most urgent threats to their health. Not only were these emergency physicians’ novice and inexperienced, but they also suffered from an inevitable tunnel vision rooted in their primary specialty, which adversely affected their practice by causing inability to take care of the often undifferentiated ER patients. Another issue, which resulted from this model of emergency care, was that some areas of emergency care did not fit well into the realms of the existing specialties and so had remained under-developed for many years. These included but were not limited to topics such as pre-hospital and disaster medicine, environmental and wilderness medicine. Last but not least on the list of problems that emergency care faced was the problem of stewardship and leadership, something that the emergency room urgently needed. With people considering the ER as a platform for their next move in their career, or as a marshland they were stuck in, one could not expect a long-term visionary, strategic plan.  Being faced with these challenges, the community of medicine resigned itself to giving birth to a new specialty: “emergency medicine”.  It was then that the now-called “emergency departments (ED)” were staffed by professionals whose first and ultimate work arena was the ED; their main interest and focus was to deliver high quality care to the critically ill and injured people who were brought to the EDs. Moreover, their training and experience were also related to the emergent situations and their broad vision and multi-tasking capabilities made them very suitable for work in the hectic environment of the ED. With increasing utilization of the EDs and diversity of the services provided, the role of these physicians in the healthcare system became more pronounced. Although first created with an intention of service delivery in mind, this new specialty has experienced tremendous advancements; changes that not only have resulted in its further establishment, but also have transformed it into an “academic discipline”. Like any other academic discipline, emergency medicine incorporates elements such as expertise, people, communities, and research areas. Formation of communities such as American College of Emergency Physicians (ACEP), Society for Academic Emergency Medicine (SAEM), and International Federation for Emergency Medicine (IFEM) as well as the scientific bodies such as American Board of Emergency Medicine (ABEM) endorsed this position and emergency medicine successfully introduced itself to the academia. Emergency medicine residency programs flourished throughout the United States and around the world and new fellowships and subspecialties emerged. Emergency medicine programs were active and vigorous and contributed a lot to the field of medical education. Research activities were also part of this movement and led to the compilation of an enormous amount of evidence pertaining to the practice of emergency medicine. These pieces of evidence have found their way into the guidelines and protocols developed by well-known scientific organizations. This added to the reputation of emergency medicine among other disciplines. In Iran, since the establishment of this specialty in the country about 25 years ago, a more or less similar path has been followed. Beginning with only one program, there are now 25 emergency medicine residency programs around the country with around 350 medical graduates entering these programs. The national board is well established and the Iranian Society of Emergency Medicine functions as a member of IFEM. Emergency medicine trained specialists are working in tandem with the most recent advances in emergency and critical care in highest volume emergency departments, which are now much better equipped than in the past. Emergency medicine has become an integral part of the medical curriculum at undergraduate level and now several other specialties also ask their residents to do a clinical rotation in the emergency department under the supervision of emergency medicine attending physicians. In addition to these achievements, one should not forget the huge share of this discipline in the research products. While there is still a long way ahead, many cutting-edge research projects have been accomplished and the results have been published in prestigious emergency medicine journals. However, the presence of a platform for dissemination of the results of these scholarly activities at a national level is an urgent need. Many researches are of interest to a national or local readership and not necessarily for a wider population around the world. Furthermore, many manuscripts are facing difficulty getting published due to non-academic reasons such as the problems with paying the publication fees or the reluctance of the journals to be in contact with scholars from Iran for political reasons (or excuses), including sanctions. With the successful experience of the first Iranian emergency medicine journal, the emergency department of Tehran University of Medical Sciences decided to launch a journal that matches the high standards of this old and outstanding university. We hope that this endeavor will provide the scholars of the emergency medicine discipline as well as other investigators with an opportunity to publish their manuscripts and benefit from the input of other colleagues. We also hope to promote the position of this journal to a well-known academic journal in the region. In doing so, the editorial board will eagerly wait for the constructive feedback of our esteemed audience.&nbsp

How Should Emergency Medical Services Personnel Protect Themselves and the Patients During COVID-19 Pandemic?

Emergency medical services (EMS) play a vital role in the management of public health emergencies such as epidemics of infectious diseases. Unique challenges, however, are expected under these circumstances beyond what occurs during normal conditions. EMS personnel often have limited information about their patients, work under uncontrolled conditions, and accompany their patients in enclosed spaces of the ambulance. They are at particular risk of contracting the infectious agent unless standard and transmission-based precautions are implemented. Appropriate use of personal protective equipment (PPE) by responding personnel is, therefore, of paramount importance. Since the report of the first cases of COVID-19 in late December 2019, the disease has spread beyond China. As of March 29th, a total of 634,835 confirmed cases have been reported globally and 29,975 people have died. The Center for Diseases Control (CDC) and other authorities and advisory agencies have prepared guidelines regarding safety precautions for EMS personnel, including appropriate selection and use of PPE

Atypical Feature of Diabetic Ketoacidosis with Low or Normal Plasma Glucose: a Narrative Review

Context: Diabetic Ketoacidosis (DKA) is a well-known emergency in diabetic patients. In a subgroup of patients ketoacidosis is present but is not accompanied by the marked hyperglycemia considered part of the diagnostic criteria for DKA. This is known as Euglycemic DKA (EuDKA). Evidence acquisition: We searched the PubMed for the existing literature on the topic of normoglymic ketoacidosis, including its prevalence, pathogenesis, and treatment.  Results: The study showed that there are many reports of the cases in which diabetic patients developed ketoacidosis without experiencing hyperglycemia. Several predisposing factors have been proposed but the precise pathophysiologic mechanisms are still under investigation. Some pathways have been suggested. Timely diagnosis is of paramount importance. Treatment is similar to DKA. Conclusion: EuDKA is a medical emergency that should be considered when evaluating a diabetic patient with ketoacidosis. It should be diagnosed and treated promptly

Lead Toxicity Resulting from Chronic Ingestion of Opium

A 32-year-old man presented to the emergency department (ED) with lower abdominal pain and constipation. He related chronic ingestion of large amounts of opium. Physical examination showed mild abdominal tenderness and gingival discoloration. Diagnostic studies showed a mild hypochromic, microcytic anemia with basophilic stippling of the red blood cells. Abdominal imaging showed no intra-abdominal pathology. A diagnosis of lead toxicity was confirmed through serum lead levels. The patient was put on chelation therapy and his signs and symptoms started to resolve. As a comprehensive search for other sources of lead was unsuccessful, opium adulterants were considered as the culprit. Chemical analysis of the opium confirmed this. Contaminated drugs have been reported as a source of exposure to toxins such as arsenic or lead. While other reports deal with patients from clinics, this report illustrates lead toxicity from ingestion of contaminated opium in the ED

Why COVID-19?

COVID-19 is a highly contagious disease caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), an enveloped positive stranded RNA virus and the third member of the family Coronaviridae which has emerged as a zoonotic infection. The predecessor of this new pathogen caused the Severe Acute Respiratory Syndrome (SARS) in 2003 and the Middle East Respiratory Syndrome (MERS) in 2012. Although corona viruses have been known since 1960’s, their familiar species were human pathogens and caused common cold and seasonal flu. SARS-CoV-2 is easily transmitted via respiratory secretions of an infected person, with a reproductive number (the average number of cases to which a single infected person will transmit the virus) of 1.4-2.5. Covid-19 has been estimated to have a case fatality rate of around 3%. As of today, asymptomatic transmission is assumed to be possible during the incubation period, which usually ranges from 2-14 days. The source of infection, animal host, and reservoir are currently unknown. In late December 2019, an outbreak of COVID-19 was reported from Wuhan city, China. The disease soon spread outside China borders and became rapidly prevalent all around the world. The pandemic announcement was officially made by World Health Organization (WHO) on 11 March 2020. Today COVID-19 has affected more than 212 countries and has made billions of people to be quarantined in their houses. Up to now, almost 1500000 confirmed cases of COVID-19 have been reported globally and the death toll has been declared to be 86000. In Iran, we are also facing this unprecedented global public health emergency, with about 65000 confirmed cases and 3993 deaths. This pandemic is beyond an expanding contagious disease and has influenced different features of life. Its enormous social, political, and specifically economic impacts all around the world are undeniable. In low- and middle-income countries this can potentially lead to a huge spike in poverty and collapse. Many vulnerable families have lost their income and access to the essential needs. Education systems have collapsed in many regions. The long-term effect of this global crisis has reduced economic growth even in developed countries. Economic effects of COVID-19 are estimated with dramatic variations. Orlik et al in Bloomberg hypothesized this cost to be $2.7 trillion. The political consequences are even harder to predict but quite significant and devastating, like the heated discussion, criticism and accusation flowing between the leaders of different countries. Since the pandemic is not yet over, the global influence will carry on to happen and make situation even more complicated. While the outbreak is evolving rapidly, health care systems across the world are actively fighting against the new virus. They have encountered many new challenges. Public health measures (such as active case finding, prompt isolation of cases and contacts tracing) to contain the spread of the disease in the society as well as provision of care for the unpredictably high number of people who are infected with the virus have stretched the healthcare system beyond its capacity. At the same time, protecting health care providers’ safety, which often requires provision of sufficient supplies of personal protective equipment, has definitely challenged the system. Societal demand for discovery of a definitive treatment and vaccine has also added to the complexity of the situation that the health care systems are facing. Studies about COVID-19 are increasingly being performed and published; many of them have not yet been fully reviewed and criticized by the academic community. Practitioners often find it difficult to find, appraise and apply the information they need amid the turbulence of their clinical practice. Furthermore, there are still many questions to be answered. The most efficient method for personal protection, methods of viral transmission, most accurate diagnostic approaches, and effective treatment options are yet to be determined. This special issue of the Advanced Journal of Emergency Medicine plans to specifically focus on COVID-19 by gathering the relevant scientific information available. We hope that by publishing high quality papers, this journal can provide its readers with further required information. Appropriate management of patients suffering COVID-19 as well as controlling this pandemic are our ultimate aspirations. We encourage further researches in this field by all scientists and physicians all across the world to be able to eradicate COVID-19 as soon as possible

Oral Oxycodone Compared With Intravenous Morphine Sulfate for Pain Management of Isolated Limb Trauma; a Randomized Clinical Trial

Introduction: Appropriate pain relief enhances patient satisfaction and reduces patient anxiety. This study aimed to compare oral oxycodone with intravenous (IV) morphine sulfate (MS) in pain management of acute limb trauma.Method: In this randomized double-blind clinical trial, patients over 14 years old, with acute isolated limb trauma were randomized to receive either 5mg IV MS or 5 mg oral oxycodone. Pain intensity and adverse effects of medications were recorded 0, 30 and 60 minutes after drug administration and compared between the groups.Result: 58 patients were studied. Pain intensity was similar between the two studied groups at 30 minutes (P = 0.834) and 60 minutes (P = 0.880) after drug administration. Furthermore, there was no significant difference between the two groups regarding decrease in pain within the defined time interval. Drowsiness was reported more frequently in MS group after 30 minutes (p = 0.006). Patients in MS group asked for more rescue analgesia. Other adverse effects were similar in both groups.Conclusion: Oral oxycodone is as effective as IV morphine sulfate in treatment of acute musculoskeletal pain following blunt limb trauma